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V" APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT w <br /> 1601 E. HAZELTON AVEJ STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora the_ <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewagmrN 1862 for cwell tlpump dl he Rules and Regulations rk herein bof he San liJoaquin <br /> Local Health District. f <br /> Job Address <br /> City 4- !I fi�Lr <br /> �. •? !yD � Lot Size PM <br /> Owner's Name ( ' i <br /> Address �r n <br /> Phoni"r'y <br /> Contractor fir, / f% P/ �,'•� r'a <br /> Krf �, { . Address` s I .` , <br /> �' License Not ,T <br /> TYPE OF WELL/PUMP: NEW WELL —Phone/It t%.s- fir- ^� �<j_ q <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION CJ SYSTEM'REPAIR ❑ "} i-,, '?oi , <br /> DISTANCE TO NEAREST: SEPTIC TANK }�- OTHER r,, , f I <br /> SEWEA LINES — _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGR low <br /> OTHER WELL <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑ Industrial ❑ Open Bottom ❑ Manieca' Dia. of WL-11 Excavation K1. ,f <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing r( <br /> ❑ Tracy Typof Casing S c L <br /> ("] Public ❑ Othe '� V Specifications <br /> n Delta Depth of Grout Seal 1 ��/= � <br /> ry� mow' — Type of Grout L,r[P, ;ar <br /> I I trrig tip ,Approx. Depth 1 I Eastern 'Surlace Sts ll installed b r1' <br /> Repanork f7�ne ❑ Tor-PumpY ` r" <br /> Type fH.P, State Work Done <br /> Well Destruction D Well DI}�terr <br /> Sealing Material Itop ') <br /> Depth Filter Material f8etow 50'1 <br /> TYPE OF SEPTIC WORK' NEW I TALLATION I I REPAIR/ADDITION I I DESTRUCTION I I <br /> ptic system permitted if <br /> available within 200 feet.) Public sewer is <br /> Installation will serve: Residence, <br /> �fYCommercial Other <br /> Number of living units: urribe f bedro <br /> Character of soil to a depth of 3 feet .__1 <br /> SEPTIC TANK ❑ Type/mf Water table depth m PKG. TREATMENT PLT. ❑ Capacity------- No. Compartments , <br /> Method of Disposal l <br /> I Distance to nearest: II Foundatio 1 <br /> Property Line <br /> LEACHING LINE ❑ No. 8 Len of lines <br /> FILTER BEDTotal length/size <br /> ❑ Dista to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS Depth Size <br /> Ll Distance Number 2kstance to nearest: Wel! Foundation erty Line <br /> DISPOSAL POND ❑ Prop" <br /> I hereby certify that I have prepared this application and that the worst will be done it accordance with San <br /> rules and regulations of the San Joaquin Local Health District. Joaquin county ordinances, state laws, and <br /> Home owner or licensed agent's signature oertirms.the following: "I certify that in the performance of the work for_NAtich this <br /> employ any person in such manner as to become subject to workman's parrnit is issued, I shall not <br /> certifies the follovA certify pe compensation laws of California."Contractor's hiring or sub-contracting signature <br /> ng:'7 cern that a[the Performance of the work for which this 't is issued. I shall employ peratxra subject to workman's cort[pensa- <br /> tion laws of California." <br /> The applicant must calf r ep required inspections. Complete drawing on reverse side <br /> I <br /> Signed <br /> bP1. (e Title: rC L �Pu O if l t <br /> u f' Da <br /> o l , p, � "F DEPARTMENT.u8 ONLY. <br /> Application Accepted by <br /> Area <br /> Pit or Grout Inspection by Date <br /> _ Fnmww in spaction by Daft <br /> Additional Comments: <br /> ❑ 5tk 46&"1 ❑ Lodi :3618621 ❑ Manteca 1123-7164 ❑7ra� <br /> pplicant- Retum an copies to:F.nvironrnentsl Henith,Pem*JSarvitbs.18p1 E.Hazbltort Ave., P.O. Batt 200!3, St1t., CA 88261 <br /> a <br /> FEE AMOUNT DtJE AMOUNT REMITTED <br /> [NFO RECEIVED 9Y DATE PERMIT.No. <br /> • EH 1324(REV,r i K si c <br /> EH[476 <br />