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, <br /> APPLICATION FOR PERMIT <br /> SAN ]OAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HA7EL,T011 AVE., STOCKTON, CA PERMIT NO. <br /> t Telephon'e, (209) 46666781 <br /> DATE ISSUED (p $ <br /> PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> i <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein " <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel pymp <br /> and the Rules and Regulations of the San Joaquin,toc''a""l Health District. f�� <br /> Job Address (_JIj, !—a j Subdivision. Name 4 <br /> owner's Name /*z Address ,Z`LZr. Phone V61 <br /> Contractor's Name X License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION.L] - t <br /> h PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LIiNES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom Mantecal Dia, of Well Excavation <br /> t <br /> i <br /> P <br /> ti <br /> Domesc/ rvae <br /> ❑ ❑ Gravel Pack � Tracy ;, Dia. of Well Casing <br /> ❑ Public Other Delta <br /> � Type of Casing � <br /> F, Irrigation Approx. (] Eastern -'� <br /> Depth Specifications ry <br /> Cathodic Protection Depth of Grout 'S eal�` <br /> p F-1 Geophysical Type of Grout i <br /> �r -« <br /> Other kr r Surface Seal Installedby 3.3 y <br /> Repa'i'r=Work-DonE-�-J�Type of Pump^ - -yH:P.:' '_, !,-,State Work Done ti j, <br /> WellDestruction U Well Diameter Sealing Material*( <br /> � <br /> Depth Filler Material (Below'S0` a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION _J (No septic tank or seepage pit permitted if public sewer is <br /> ;.available within 200 feet.) ro <br /> is Installation will serve: Residence X Commercial Other <br /> Number of living units: _� Number of bedrooms :7— Lot.size '70 <br /> Character of soil to a depth of 3 feet: V ct Water=table depth ,:S7D <br /> i SEPTIC TANK Type/Mfg COAZAfCapacity /2_0 No. t6;partmen`t�_ �- <br /> PKG. TREATMENT PLT. -,•Type/Mfg Capacity Method of Disposal <br /> �f <br />! SEWAGE SYSTEMS '~�` pist nee to near-est: ;Well _j Foundational ti Property Line 1. + <br /> DESTRUCTION_ ❑_ x F •a.. T _ �/ _ - '�+ <br /> ` LEACHING LINE V4'No. & Cevgth'of�li s Total length size <br /> f - <br /> FI LTER.I3ED pistance to nearest: We,, Foundation /Q ' Property Line <br /> � w <br /> iSEEPAGE PITS Size " Number <br /> SUMPS LaG Distance to Well Foundation '_ PropertyLine„ _ <br /> DISPOSAI. PONDS <br /> °i <br /> I hereby certify that I have prepared this application and that the work will-be-done-in­aceordance-w.i.thAaJoaquin county j <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local'Health District;' ' ! <br /> Home owner or licensed agent's signature certifies the following: "I certify that in,the,performance of the work for which this <br /> permit is issue I shall not employ any person in such manner as to become subject*to Workman5.compensation.lawslof California.” <br /> Contractor's h' ng or sub-contracting signat e certifies the.following: "I certify that in tle'`per'formance•of the,work for which <br /> this <br /> per <br /> i ss ed, I sha 1 employ rso subject to workman's compensation laws of California." - "` <br /> The applica m call fo all re e ectio s. Complet' drawing on reverse s'ide. ' ` <br /> 6 <br /> Signed , Title: Date: r <br /> FOR TMENT,USE ONLY f <br /> Application Accepted Areai, T -•- �0. 'YO-Stk---�466�67,81 <br /> Additional Comments: ` tf fLodi' 369-3621 <br /> Pit or Grout Inspection by 4� V ,Date �� Manteca 823-7104 1 <br /> Final Inspection b'y - Dafe p Tracy 835-6385 <br /> Applicant - Return all copies to: Envi nmental Health.Perinit%Services'1601 E. Hazelton 1Sve., P.D. Box 2009, Stk., CA 95201 <br /> I <br /> FEE SASE AMOUNT. DUE AMOUNT REMITTED ;`: RECEIVED BY DATE -�PERMIT N0. x <br /> INFO __ �_✓_ a L <br /> 7 fi0 22. 500;;_____... <br /> 14-26 <br /> 1 <br />