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<br /> APPLiCATION FOR PERMIT
<br /> q SAN JOAQUIN'' LOCAL HEALTH DISTRICTop
<br /> 1601 E. HAZLLipiVIIVE., STOCKTON, CA
<br /> Telephone t:_39i 466-6781
<br /> f PERMIT EXPIRES 1 1/EAFi FROM DATE ISSUED
<br /> s --
<br /> d=}`r (Complete in Tripiil atr3) O �D —
<br /> :L Application is herol,y made to the San Jnaquin Local Health District for a hermit to construct and/or install the work herein dascr ba i.7h s application s
<br /> made in corplianc,•with San Joaquin County Ordinance No.54,9•Lor saws e.or No.iilfi2 for well/pump and the Rules and Regulations of h
<br /> ' Local Heeltl,District. 9 the San Joaquin
<br /> (i r cl ` '^
<br /> Job Address — �� •
<br /> City�_' ='C� yZ Lot iize P!N .
<br /> if
<br /> §L t' lily,
<br /> Owner's Name
<br /> dress
<br /> -- _ Phone
<br /> F' Contractor
<br /> .-.-� tees. '1( No. Phone
<br /> U_ _ =1�'_Ll` � � � r
<br /> fi;
<br /> •+ cense _
<br /> TYPE OF WELL;:' NEW WELL ❑ WELL REPLACEMENT Ll
<br /> DESTRUCTION L7 r
<br /> PUMP INSTALLATION C]
<br /> SYSTEM REPAIR C7 OTHER 0 "
<br /> 1
<br /> q`P DISTANCE TO NEAREST: SEPTIC TANK _-_ SEWER LINES —, DISPOSAL FLD. PROP, LINO'
<br /> R FOUNDATiON _— AGRICULTURE WELL _—_ OTHER V%,E!L_ PITS/SUh1PS
<br /> yr INTENDED USE TYPE OF WILL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> �'
<br /> ' �7 Industrial ❑Open Bottum ❑ Manteca Gia. of Well Exeavat#on :
<br /> fh a Lola,of Welt Casing yak
<br /> Q Domestic/Private I I Gravel Pack i,,Trac
<br /> _ Y Type of Casing Specifications
<br /> rr; 2 Public Ll' Other 0 Delta Depth of Gr
<br /> nut p Seal, Type of Grout_ :��
<br /> A d Irrigation --Approx. Depth r' Eastern Surface;Saal Instelled by,_
<br /> Repair Work Dore ❑ Type of PumH.P. t s
<br /> p State Work Done Y�'.
<br /> .,
<br /> ' Well Dest,uction ❑ Well Diameter Sealing Materia(top 50') w m t
<br /> Depth�.-. Filler Material(Below 5o') _ 1
<br /> a"9 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Cl DESTRUCTION:-1 '.No septic system permitted i;public sewer is
<br /> �'•y r
<br /> / available within 200 feet.)
<br /> fnstalla'ion wif!Serie: Residence Commercial Other
<br /> Number of living units:4-- Number of bedr ms
<br /> Character of soil to a depth of 3 fee,:—C-
<br /> SEPTIC
<br /> lYGIZ�� Water table depth
<br /> �= SEPTIC TANK ❑ T /Mf
<br /> cf3 Ype 97 _ CapacityC 0� No. Compartments. " r.,
<br /> wr is PKG. TREATMENT PLT.© ;4—
<br /> Method of os31 _ °" _t 's+.
<br /> Sr `S 1 r
<br /> Distance to nearest: Well/ L' ..{Q
<br /> { -- Foundation_ Property Line '— 1:,•y a�
<br /> LEACHING LiNE., No.& Length of lines � i gi" t
<br /> 4 zt � � Total length/size 71/ _
<br /> �' '• FC-TER BED gyp/ '14,
<br /> =
<br /> Yed l. Distance to nearest: Well Foundation lU Property Lina SU 5.a,.
<br /> t" r �rru t i
<br /> �° vS.. Y
<br /> Y h SEE^AGE Firs :£ Depth Size
<br /> Number
<br /> e } ` r
<br /> yy4f SUMPS , ❑ Distance to nearest. 1�lell� [t� Foundation�f�r _ Property Line '�y• " o1 kFs f
<br /> } DISPOSAL PONDS CJ M e -
<br /> Ydlt':
<br /> r t- 1 hereby rertify that I have prepared this application and that the wort;wilt be done in accprdance with San Joaquin county ordinances slate laws`and r
<br /> f a rules and regulations cf the San Joaquin Local Health District.
<br /> 3k s
<br /> home owner or licen-ad agent's signature certifies the following:"I certify that:n lite pmrformance of ttie work for w!tich this permit is issuedi shall of , y"
<br /> sr.ttploy any s tom person in SL-h manner as to become subiect to workman'
<br /> p..'cellon laws of Caiifomia."Contractor's hiring ar sub-contracting signature a; 6" a.
<br /> certifies the following:"E c.:aify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's eompensa-
<br /> tion laws of Caifomia." y.,
<br /> t The v licant
<br /> Signst c r
<br /> }fir ,r pP qu6d" s�ctions.Comp!gte tawing rue side.
<br /> ?� yt ed x`-,c%7�� i'�, Title: DatAmd s
<br /> R DEPIRFIThAEN SE ONLY yips
<br /> ApplicaCon Accepted by Date •� •" �, •�•/ .,4-�_�• '}�`
<br /> !M r;
<br /> ' >�}: Pit or Grout Inspection by !`• Date nal Inspection by—
<br /> - Date j
<br /> {L fi` hoditional Comments: .
<br /> e� Stk 466-6781 0 Lodi: 366-3621. Q Manteca 813-7104' l� f racy F25 C'3B5 1j`/--^.—� c4
<br /> apf]ficant-Re ern all copies to: Environmentrtl Health Permii/Services 1601 E. Nalzaltor,Ave., P. Box 2009, Stk.,OA 95201
<br /> VEE -AMOUNT OtJE' AMgUNT RF.rdITTID CK x
<br /> CASH RECEIYEp BY "DATE, PERMIT NO..- -h r•
<br /> EH12-24(REV.1/M 5) - !, (- •/l�
<br /> EH 14-2a
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