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A - <br /> b <br /> APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVEP, <br /> Telephone 1209). 466.6781 APR 5 �a�p <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E111`IjRONMEN�AL <br /> (Complete in Triplicate) p �� NFALrh <br /> t �TFWGC�. <br /> Application is hereby rr:ade to the San J0a3wn Local Health District fur a permlr to construct and'ar:nstalt the work herein desur n <br /> made in compliance with San Joaquin Counly Ordnance No 549 for sewit}e or No 18152 for wttfrpump and the Rtes and RegutaGuns of the San Joaquin <br /> Local Health Datsrct. S 7 a e'er. 6,Jj#0(v Address ry�y� <br /> JM <br /> _ City / �� lot Site -- — PM <br /> ,. rQ Address Ls- _ F I +L/(,LPhanat�lLc1� �G <br /> < Owner't Hama � •�-'/ p ,+ <br /> 0 f? A{ y/�Cd�ress L. :�glij �'1+ L catse Na. S 9� Phone(9 6 38 7 <br /> -7 6, <br /> Contractor a"' -- z <br /> TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT Tl DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINTS DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL__7=5��2t PITSISUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ll t <br /> L�Industrial ❑Oper.6altorrt ❑Manteca Dw.of Well Eecavantian� �' Oia.of Wea Casing <br /> Type a}Casing, Jt- Specifications <br /> M Dcimestic/Private he Gravel Pack KTracy g _r4.0-Jr ed."w,f <br /> i'I Public 1-1 Olhei tC1 Delta Depth of Grout Seal _4 Type of Grout !r <br /> —_Apprax.Depth l I Eastern Surface Seal Installed by <br /> I 1 irrigation State Work Done_ <br /> Repair Wort Done L3 Typo of Pump - H.P• <br /> Well Destruction ❑ Well Diame[ar Sealing Marerial(top 501 <br /> Oepth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I OES1'RUCTION I I Wo septic <br /> system <br /> ilhin m ).tatted it public se vet is <br /> Insiablion wiil serve: Residence_ Commercial_ Other <br /> Numbor of living units: Number of bedrooms <br /> Character of soil to a depth of 3}ear: Water table depth _ <br /> SEPTIC TANK ❑ TypelMig Capacity Me Compartments <br /> PKG,TREA.HENT PLT.❑ Mallu:-J of Disposal <br /> Distance to nearest. Welt Foundation _ Property Line <br /> W LEACHING LINE Ll No.6 Length of tines Total lengthlsite <br /> FILTER BED ❑ Distance to nearest: Wed Foundation Property Line <br /> SEEPAGE PITS :l depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this;,�pllcabon and that the work will be done in accordance with San Joaquin county ordinances,sate taws,and <br /> rules and regutttiara of the San Joaquin Local Health Ddtrict. <br /> home owner or licensed agent's signature certifies the fo{awing:"I certify that in the performance of the work for which this permit is isswrd.I stun not <br /> re <br /> &nVicy any person in such manner as to become subject to workman's cor ipensation taws of California."Ca ay poisons <br /> hiring or w`r orli se's c nVen 3- <br /> cartir*s the fodowirV."I certify that in the pertormarwA 01 the work for which this perm t is issued.I shad emp ay persons subject to wCrkmari s compensa- <br /> tion laws of California." <br /> The applicant�t call for al nraqurred tions.Complete drawing on reverse side. <br /> Signed. /!S's � �� <br /> Title: I G� l. data: _ <br /> FOR DEPARTMENT USE ONLY <br /> Application Aeeepted by Dass Area <br /> lL /10 <br /> Data Final <br /> ----------Pit or Grout Inspecti0n bY__ Ins Dass <br /> - — -- Inspection by <br /> Additional Comments: <br /> ❑ Stk AW-Ml <br /> 3643 1 ❑Manteca 821 ilU1 l7 Tracy f3ISS�5 <br /> _... Appllcart.Return a1 copies to:Envirn <br /> omental Health Perrnit/Services 1601 E.Hazelton Ave..P.O.Box 2009,Stk.,CA 9520! <br /> FEE AMOUNT DUE AMOUNT REMITTED A H RECEtVEG BY DATE PERAt7:•N0. <br /> INFO <br />