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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (20 466-6781 <br /> PERMIT EXPIRES 1'YEAR..FR6M DATE ISSUED y <br /> i. (Complete in Triplicate! ` <br /> # a mtit.to'.©oi struct and/or install the work herein described.This application is <br /> ,p�lioetlori �,Qpy rnsde she&nn Joaquin Local Haafth District ot. Pa 111 and the-Rules and Regulations of the Son Joaquin <br /> wit <br /> on J uin Oountyrdupanca�Nt.649 for xewaQa or Nci 1902 for�rva pump <br /> � made,n Compliance: h 4�eq <br /> S,Local He81t11Dtatrict. <br /> r _ a tOt S PM <br /> Gty <br /> -041 <br /> Sob Address F f <br /> A Y ✓�" ��' ddrass � .. <br /> Ovvrtels!lama .« <br /> kL7 i' I'17t)n <br /> •.Lkense.#fo. <br /> `Contrac�4or.. <br /> �>f�EW WELL,.❑ :.WELL REPLACEMENT,.13 DESTRUCTION ?; <br /> 'TyP! OF WELLlP.UMP SYSTEM REPAIR ❑ <br /> OTHER,[I <br /> PUMP INSTALLATION:13 i <br /> DISTANCE TO NEARFST:.SEPTIC TANK <br /> SEINER LINES DISPOSAL FLO. PROP. LINE <br /> OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> AGRICULTURE:WELL <br /> + <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of wait Casing i <br /> rl Industrial .❑ Open Bottom- ❑ Manteca Dia. of Well Excavation - I <br /> Of Casing Specifications <br /> E] Domestic ❑ (34xvel T Pack ©Tracy Type Type of Grout ' <br /> 1-1 Public [l 011ier C-1 Delta Depth of Grout Seal i <br /> I i Irrigation _Approx. Depth I.1.1aste_rn Surface Seal installed by ; <br /> Repair Work Done <br /> ; <br /> L3 Type?f Pump �- _fl H.P.. <br /> State Work Done {� <br /> Seat Matsnal atop 50'I <br /> ti: z <br /> Well Destruction'- ( -Well Diameter ^� , <br /> W <br /> F Qeptf# Filler Material(Below lit)')., ' <br /> TYPE OF SEPTIC WORK:. N 1NSTALLATION- 1 :f;EP IRlADDITION i'I DESTRUCTIOtI t .laNvaoilblettwith n ftt�sd tl public sews+is j <br /> Instsl4at�iaon;will senre+cRostdeftce --- moi Other -.-_ <br /> unumberte`-. <br /> Number.&livingks:< Nr of bedrooms Water table dept j <br /> Character of sod to a depth of 3 feet: <br /> r. N0''` <br /> %p Tips/Mfg <br /> SEPTIC;TANK s Capac p <br /> , x <br /> .; k R Method of O'isosal <br /> Pi.G TREATMENT PLT D " a <br /> a `' Foundation —�s 1'roportYLine.�, ­ ..-.i_.r <br /> - , - Qtstance to nearest k. <br /> F <br /> Welt�..:�... <br /> a^ -e <br /> LEACHING LINE ❑ No..i5 Length o1 Tota!length/ <br /> rl ILTER BED ❑ Distance to nearetit: W Foundation <br /> operty'Lir►e <br /> ;.�.8' ..�. ` <br /> S E PITS <br /> AGE 1.1 Depth _- -�.,,�-- ( f c <br /> Number <br /> •.5 CCI Distance to nearest: WI Foundatia Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I,have.prepared this application and that the work will be done in accordance with San Joaquin rAunty ordinance, state laws,`end <br /> rules and regulations of the San Joaquin Local Health District. <br /> i certify that in the performance of:the work for which.this permit is issued,-1::shall not <br /> Hornevpwner or licensed agent's signature <br /> certifies the foi,owing: " fY <br /> employ eny person in such manner as to become subject to workman's compensation laws of California."ContrecEod s hiring of sub contracting signature <br /> Certifies She 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 caf.California II fo I equ <br /> t ,. . <br /> The app ed inspectlons. 'o ere drawl fort`reverse side: f <br /> 4 r. f Date/ <br /> �- Tit, <br /> Signed I <br /> FOR DEPARTMENT USE ONLY <br /> as <br /> Ap fication Accepted E <br /> ar Grout In by <br /> �' f p e. '{r Final.lnapbctior► 6G'� Dste _ <br /> �. <br /> Additional Comments:._ <br /> ❑ Stk 466.6781 ❑ Lodi ,369-3621 . ❑ Manteca 823.7104 O Tracy 835.6365 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E{.Haxslton'Aya., P.O. Box 2049, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'k0.7 <br /> y INFO <br /> EH 1426 ' s' Yt }:} ,7 "4 <br />