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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT P Ay M FENT11 <br /> -tvF <br /> 1601 E. HAZELTON I AVE., aF STOCKTON, CA CF —0 <br /> L/ Telephidne (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ,ISSUED- <br /> - 1— <br /> {Complete.in Triplicate/' HEWN <br /> NVIRONMENTAL <br /> a e work herein d 4"'66ion is <br /> Application is hereby'made 2 <br /> �,brq 5 "N Xthe San Joaquin <br /> ade to the San Joaquin Local Health District for a permit to construct and/or install the 91.9 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Re ons., <br /> Local Health District. <br /> G. t. PM <br /> Job Address 61ty 'to z <br /> Address Pho�e <br /> Owner's Name <br /> r"I NO <br /> Address (94DO3& ,6&�) License Noe� Phone <br /> Contractor—r. <br /> NEW WELL El WELL REPLACEMENT D DESTRUCTION 11 <br /> TYPE OF WELL/PUMP: PUMP INSTALLATION C1 SYSTEM REPAIR X. OTHER Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL— PITS/9UMPS-­-1, <br /> INTENDED USE -TYPE OF WELL PROBLEM AREA ;CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial 11 Open Bottom ID Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private L-Gravel,Pack 0 Tracy 'Type of CasingSpecifications <br /> 0 Public El Othe-r tepth of Grout Seal Type of Grout <br /> C1'Delta - i <br /> El Irrigation ---Approx. Depth 0 Eastern -Surface Seal Installed by <br /> Repair Work Done Type of Pump S, H.P. I State Work Done A0"A(,f-('— <br /> well Destruction ' ,E] �Well Diameter Sealing Material (top 50'1 <br /> Depth* I Filler Mat4rial (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION El (No septic system permitted if public sewer is <br /> F available within 200 feet.) <br /> Installation will serve: Residence—I, Commercial Other <br /> Number of living units: --rtt1­ll4UfiiI5e—rof bedrooms -5 <br /> Character`60so'll to a-delA of sfeei: Water table depth <br /> ­­�. . I _ Capacity_ No. Compartments OQ <br /> SEPTIC TANK El Type/M:fg Method of Disposal <br /> PKG, TREATMENT PLT. ID <br /> L Distance to-nearest:�Well�-- --Foundation-- Property Line <br /> > <br /> LEACHING LiNiE-4- ❑ No'A 1­1'66-th of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Found Property Line <br /> Foundation.�� J­ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS D <br /> `�% �,� �,N 1�1 istance to neare's't: sJ Well— Foundation— Property Line <br /> DISPOSAL PONDS <br /> .1 hereby certify that I hav*eprepared this application' lication and that the work will be'done in accordance with San Joaquin county ordinances;state laws, and <br /> ' ' <br /> -rules-and regdlatiqr)d.of.the San JoaquiriLdcal Health'Dislfict. <br /> Home' - �Ii8ense'a0erit's signature certifies ih6 following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> H me owner or d signa <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting14. <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compen <br /> tion laws of California." <br /> The applicant t call for all requir chns ct' ns. Complete drawing on reverse side. <br /> Sign d X— Title:` Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted-by Date Area <br /> Pit or Grout Inspection� Date Final Inspection by Date <br /> Additional Comments: — <br /> D Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 ED Tracy 836-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave. P.P. Box 2609,'Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'fiO.' <br /> ZX9H <br /> + EH13-24 4REV.-i 115) <br /> EH 14-26 <br />