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b <br /> A <br /> APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT Id G <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA � <br /> Telephone (209) 466-6787: i <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED !j <br /> „K lComplete in Triplicate) <br /> cation is <br /> Application is hereby made to the San Joaquin Local HealthNo.District49 for sewage or No�1$fi2 forct and/or welllpump install <br /> nd the Rules and Regulations of he Sanappl'Joaquin <br /> made in compliance with San Joaquin County Ordinance <br /> Local health District- <br /> PM <br /> ,3� -�_ , � �. City ��� Lot Size J PM <br /> 4 <br /> Job Address - Z <br /> J1I _ <br /> k9 <br /> Owner's Name 'v Address <br /> T . .. ,61 1- 017 <br /> ��5 iii"es License No� � Phone <br /> Contractor AdL <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> x ] OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR i <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL_FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 4 -119 <br /> j �a ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0, <br /> ❑-Industrial . -----� -t Spec'�ications <br /> T of.Casing-r r-- -- <br /> 1 Oipomestic/Pri3ate' ❑ Gravel'iPack <br /> El Ype ' T of Grout <br /> i ❑ Public f' ❑ Other ❑ Delta �. �-. Depth of Grout Seal Type <br /> c <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal,lnsta' k bye I l <br /> H.P. =Z_1'Stet Work Done <br /> Repair Work Done ❑ Type of Pump <br /> on ❑ Well Diam <br /> eter Sealing}Material (top <br /> Well Qestructi <br /> Depth !' Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) � <br /> Installation will serve: Residence-A Commercial— Other 4Z <br /> s • S� <br /> 4 Number of living units: Number bf bedropms Water table depth i <br /> Character of soil to a depth of 3 feet: ? <br /> ❑ Type/ Capacity No. Compartments <br /> SEPTIC TANK } <br /> Method of Di <br /> PKG. TREATMENT PLT. ❑ ss / � + Property YLinep <br /> Distance to nearest:- Well 6DFoundaton T' <br /> j ^^ TTallength/size <br /> LEACHING LINE ❑ Nd. & Length.of-lines �� Foundation /0 - Property Lines <br /> FILTER BED ❑ Distance to near st;`:Well 50 ; <br /> ;.t <br /> Number <br /> SEEPAGE PITS Ll Depth y Size <br /> ' <br /> Foundation Property Line <br /> . SUMPS ElDistance.to nearest: Well t <br /> 'DISPOSAL PONDS ❑ } i <br /> t I hereby certify that 1 have prepared this applicabon'and that the work will be done in accordance with San Joaquin county ordinances, st Ite Paws, and <br /> F 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 permit is issued, I shall not <br /> I employ any person in such manner as,to become�subjeci to workman's compensation laws of California.'Contractors hiring or sub-contracting signature <br /> certifies the following: -I certify that in the perfor ente�f th4 Work for which this permit is issued,l shall employ persons subject to workman's compensa <br /> tionlaws of rnia." } a- <br /> The <br /> applic t m t c for all r e inspections. Complete drawing on raver side. <br /> Signed 1 y Title: Date: <br /> { FOR DEPARTMENT USE ONLY / 2 <br /> I i Date �b -�ll�"r'� Area <br /> Application Accepted by z <br /> ` I Date Final In <br /> by Date <br /> Pit or Grout Inspection by I <br /> C/ v!4�c— <br /> Additional Comments: r <br /> ❑ <br /> Additional <br /> 466 6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> onmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> Applicant- Return all copies to: EnvirStk., CA 95201 / <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> !Eg <br /> NT DUE AMOUNT REMITTED CASH <br /> + EH 13-241REV.t/B5) <br /> EH 14-25 <br />