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. . <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCA HEALTH DIS 1..tCT <br /> �- 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Te1eph6he (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> } (Complete in Triplicate) ;' <br /> all the worl�herein <br /> . This <br /> catiOn is <br /> Applrcanoom )ranee wmade <br /> Sanothe Joaquin County Ordinan Joaqu; t to const") <br /> in lnce Nn.549Health Dirfor sewage tirict for a 51No. 1862 for cwelllfpump and the R les and Regulations of the.Sart'Joaquin <br /> made in P i' <br /> Local Health_ District. <br /> .lob Address <br /> City IC Lot Size PM <br /> 12-alk /71 t C Phone CCS c � <br /> Owner's Name Address /' y� <br /> Contractor <br /> 1 (f h Address� 1�. I _Ca �- ¢ License tEo:� _ Phone y <br /> TYPE OF WELL/PUMP: NEW WELL LJWELL flEPLACFMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION, 0SYSTEM REPAIR Cl OTHER EI , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' 'DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL : PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E1Industrial ❑ Open Bottom ❑ Manteca Dia.!'of Well Excavation Dia. of Well Casing <br /> ❑ DomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public ❑ Other 4_1 Delta Depth of Grout Seal Type of Grout' --- <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - <br /> 4 State Work Done <br /> Repair Work Done L7 hype of PumpH.P.}_-_�_— �f. <br /> Well Destruction i PK Well Diameters' –may Sealing Material (t m_ <br />€ 00 <br /> Depth ' r y Filler Material i8elow tl�l ' - —= <br /> TYPE,OF SEPTIC WORK: NEW INSTALeM IVd I AIR/ADDITION t 1 DESTRUCTION 1,l (No septic system permitted if puhlic sewer is <br /> C 'available within 200 feel.) <br /> Installation will seryQ <br /> e: Residence Commlrcial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. LlMethod of Disposal <br /> 'i <br /> Distance to nearest'. Well _ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of livres Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> E <br /> SEEPAGE PITS I 1 Depth Size_—_. Number <br /> SUMPS Ll Distance to nearest: Well FOundalion_ Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will,,be done in accordance with San Joaquin county ordinances,-state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of theworkfor which this permit is issued, I shall not <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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required ins ctions• Complete drawing on reverse side. j', <br /> Si nod X Title: �l!'C f�r _5- Date: •, <br /> Sig I <br /> FOR DEPARTMENT USE ONLY , <br /> Application Accepted by fDate U Area <br /> Pit or Grout Inspection by/1 Date L Final Inspection by Date la <br /> Additional Comments: (I CGS Gr C I f e eo ewl U f (t - <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 623-7104 € ❑ Tracy 1335-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> ,• EH 1124(REV.r/R sl J�C.^�. <br /> EH 1480 J <br /> fF .. <br /> l <br />