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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 <br /> -- (Complete in Triplicate) <br /> _ m Loral Realm D•stnct for a permit construct and/or install the work herein described. <br /> Application is heiehy made to the Sin jaqu <br /> This app6eotion K <br /> made in compliant-with San Joaquin County Ordinance No.549 Inr snwa0a or No. 110;2 to <br /> well/porno and the Rotes and Regulations o1 tot'San JoaQtu^ 31 <br /> Local Health Dishict. D <br /> /L r GGD Lct Site�7'�-Y 300 PM <br /> Job Address J2_t=�_. iC����1 city----�- e to <br /> // Phone •!/L �lnT/3 r <br /> Owner's Name Address <br /> - fY7L Phone r-ay7/ <br /> Coniroctor <br /> FLC'yD r /�'�-f!> Address_z- -�1?E��s�'-7--A�f License Na.�7' <br /> TYPE OF WELL%PUMP: NEW WELL i.i WELL REPLACEMENT i.1 JEST RUCTION OTHER O 0 <br /> PUMP INSTALLATION I' <br /> SYSTEM REPAIR L] <br /> • SEWER LINES _ DISPOSAL FLD. PROP.ZINC <br /> DISTANCE TO NEAREST: SEPTIC TANK - PITS!SUMPS <br /> FOUNDATION ._ - AGRICULTURE WELL OTHER WELL_ <br /> INTENDED USF. TYPE OF WELL PROBLEM AREA CONSTRUCTIO`J SPECIFICATIONS <br /> Dia.of Well Geeing <br /> L]Industrial Q Open Bottom u Manteca Dia. of Well E•cavahun Specifications <br /> Type o1 Casing <br /> Domestic/Private I_l Gravel Pack D Tracy Depth of Grout Seal _ Type of Grout__ <br /> I'1 Public <br /> 1-1 Other E Delta <br /> I I Irrigation __•_Appiox. Depth I I Easton Surface Seal uutalleil by — <br /> Repair Work Done l.] Type of Pump <br /> H P. _—--- State Work Done-- <br /> - Scaling hlatenal(:)1) 0'1 <br /> 5 <br /> Well Destruction l-' Well Diameter Filer Material IBe1nw 50'1 .-- <br /> Deplh - rmitted if public sewer is <br /> 1YPE OF SLi; C WOR I':. NEW INS1 ALl A I ION I I HEPAlIi/ADDI IIUN f�i i)f y'"Ll <br /> CTION I ' �vailablieiw thin 200 feet.) p - <br /> // Other_--_-_.- <br /> ? installation will serva: Residence-L. Commerc!al_- <br /> Number of living units:_- <br /> Number of bedrooms�_— Water table depth_ <br /> .. C/-gym-�1�+�'-n� ---------. <br /> Character of sort to a depth of 3 feet: - No.Compartments ._ <br /> SEPTIC TANK (.l Type/MlU __ 1✓= ✓�--• l'apacdv.--- <br /> Method of Disposal _ <br /> PKG.TREATMENT PLT.Ll Pra rt Line <br /> \'dell Fourd.ttinn-.-_-- Pe v <br /> � Distance Ir nearest: /.. <br /> /—T�------ Total length/size�' <br /> LEACHING LINE I�No.6 Length of lines _�l�L...----- —"-" -�O ' <br /> �f Fmmdation _� - Property line. _ <br /> FILTER BED C1 Distance to nearest Well-�---- _ O <br /> Number _ <br /> f,( Depth <br /> SEEPAGE PITS Foundatron _//�.— Property Line <br /> s I I Distance to nearest: Wall_10.o— <br /> SUMPS <br /> DISPOSAL PONDS I1 Joaquin count ordinances,state laws.and <br /> I hereby certify that I have Proparenl this apVGcatinn and Inat the work will be done in dccOrdance with San Joaq y I shell.not ' <br /> rulos and regulations of the San Joaquin Local Health District. ­t <br /> Pe <br /> Home owner or licensed agent's signalure certifies the toliowin 't certify that in the Ix,dormanca of the work lot which this r's hiring ur tib- o issued, <br /> I zn person in such manna,as to become subject to workman's compens tx ws of alifiami emplovaperosons subject o work tman's ompensa- �}'' <br /> employ y Pe is <br /> certifies the following:"I earthy that in the performance o1 the work for which permit <br /> tion taws of California." Q <br /> wing on r <br /> The applicant must cell for all required inspections.Complete dra� Title: <br /> reverse side. <br /> para. ~ - �-90 <br /> - ;- <br /> .. Signed X_C' <br /> y -- ('9 <br /> { FOR DEPAR ENT USE O Y 1 <br /> r \y)L Area <br /> �- Date <br /> Application Accepted by ��A•� -t- oats O <br /> Data - Final Inspection by��6/ <br /> i Pit or Grout Inspection by�., - <br /> T Additional Comments: 1\ r Tract/ 83 5 , <br /> O Stk 466-6781 l7 Lodi 369.3621 <br /> Manteca 823.7104 O <br /> !I Applicant-Return all copies to:Environ menta Health Permit/Services 1601 E.Hazelton Ave..P.O.Box 2[109.Sik.,CA 95207 <br /> CKIIECEIVED BY DATE P-1-11 NO. <br /> FEE OUNT DUE AM NT EMITTED CASH r <br /> INFO <br /> . »:.,-E,., <br /> J9s'3 7 V <br />