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APPLICATION FOR PERMIT <br /> ¢ `SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED y <br /> (Complete in Triplicate) 4A Lf/F!G <br /> Appicaon is /or install the work <br /> n describ .This <br /> cation is <br /> madle inti <br /> compliance withdSanoJoaqu nthe SanCounty Ordinance No.549 for sewage or Joaquin LocHealth District for a permit <br /> 1862 for cwell/dpump and the Rules and'R gulations of he San l Joaquin <br /> Local Health District. r�, <br /> I%N \h. � /f(/7e sty! ��✓ City. — Lot Size /DetC�vc PM <br /> Job.Address _r r <br /> c�4�..LTA-.� P 'Inn fry 4J Address �6/SI /� //t1✓ 9g op Phone <br /> Owner's Name 1+� 4u �` .209 - <br /> \t..r <br /> Contractor �/ / Address %r se�No:-� r�y "Phone--- -'^3 <br /> TYPE OF WELL/PUMP: N WELL ❑ ^WELL REPLACEMENT 0 DESTRUCTION LI IysWtfnY' we a. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHEq) <br /> OP <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P . LINE — <br /> 1 PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. fi Well s_S�yd <br /> ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing <br /> (7 Public <br /> [71Other F) Delta Depth of Grout Seal � Type of Grout.Q"L4 <br /> I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by --Tam 4- <br /> 1 — __ -�—H-P—_ _ State Work-Done <br /> Repair Work Done--O Type of Pump i <br /> Well Destruction ❑ Well Diameter -. Sealing Material (top 501 <br /> Depth" J fillerMeterial (Below 50.1 <br /> ll TYPE OF SEPTIC WORK: NEW INSTALLATION'I 1—FIEPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is.'j" <br /> r available within 200 feetJ <br /> Installation will serve: Residence— Commercial_ Other / 1'4� <br /> ' Number of bedrooms <br /> Number of living units:u_,�.„ .. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Capacity No: Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> l _ Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r1 FILTER BED ❑ Distance to nearest: Well Foundation PropertyLine G <br /> ' SEEPAGE PITS 1 I Depth Sze_ Number�' _ <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS"—'❑ .^ `---mfr ` r <br /> I hereby certify that I have prepared this application ancitthat the work will be done in accordance with San Joaquin county ordinances,state laws, ant <br /> rules and regulations of the San Joaquin Local Health District. I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall no <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <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 compensa <br /> tion laws of California." r <br /> The applicant must call for all required ins a tions. Complete drawing on reverse side. , <br /> - Title: Ae :& Date: S /2 <br /> Signed X I <br /> I t FOR DEPARTMENT USE ONLY _ <br /> Application Accepted by ! Date/ Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection'6 Data V <br /> Additional Comments: - <br /> ❑ Stk 466-6781 -"—El Lodi_369-3621,,, _"El Manteca, 823.7104 ❑ Tracy 835-6385 Stk.�CA 9520— <br /> Applicant- Return all'copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> i "FEE`_' -_ AMOUNT DUE AM6UNT REMITTED C rREDEIVED BY DATE <br /> PERMIT'NO. <br /> INFO G <br />