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y <br /> 21 APPLICATION FOR ?E'RR,':T <br /> c4a li� •� <br /> SAN JOAQ6!N LOCA A.LTH.-DATRICT ' <br /> I ' AR PERMIT NO. <br /> 1601 E. HAZELTON .AVE., STOCKTON, CA <br /> Telephone (1209) 466-67B1 DATE ISSUED <br /> 0. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Co plete iri Triplicate} ZS-3-3co' 29 <br />` �D uJ• 2)c�4,41 sq/`4 ,/� r I f T N <br /> Application is herepliccamade <br /> onois:the <br /> madeSan <br /> inocompliancelwlithlSanDJ Joaquin Countyistrict for a p0 dinanceermit cNoSt549tfor dsewage sorl.Noth1862rforewell/pump <br />�. described. This app <br /> and the Rules and Regulations of the San Joaquin Local Heath District. `"/�js <br /> Job Address U Phone' +I{¢"'�' <br /> k Address-i` s <br /> f Owner's Name icenseNo. ��� Phone <br /> ( _ Contractor's Name <br /> 41 <br /> � Lj� � <br /> 44 <br /> NEW WELL WELL REPLACEMENT [, DESTRUCTION (- } <br /> r TYPE OF WELL/PUMP IJORK: pTHE•R_U Pi. - <br /> —PUMP-INSTALL-ATI.ON�-�--.SYST•EMI�REPA. LINE <br /> R -- I—^"- PROP. T� <br /> ...i•` *". „-^ "" `"_ - �-� DISPOSAL FLO. -0 <br /> I 5 ,r�+� <br /> I <br /> DISTANCE TO NEAREST: 5EP71G TANK _ SEWER LINES'.e 41 OTHER r• • PITS/SUMPS <br /> r"�'� WEtiLL .. <br /> y FOUNDATION C�� AGRICULTURE?WELL;ice. , <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> IJ industrial <br /> U Open Bottom []Manteca: 'al of Well Excavation �r <br /> Tracy Dia. ofr"Well.Casing <br /> i ❑ Domestic/Private Gravel Pack �r <br /> Public F1 Other L]Delta Type of Casing S� /arL <br /> Xlrrigation prox. Eastern Specifications <br /> f G 4 <br /> ' ❑Cathodic Protection Depth Depth of -rout, Seal � <br /> I <br /> L-1GeophysicalType of Grout, <br /> a x <br /> �f Other Sur ace Seal Installed by° <br /> t ♦.c�1 L � !� <br /> l H p b State Work Don 2'"-'`"�'� t I <br /> I <br /> 1 Repair Work Done ❑ Type of Pump t <br /> SealingrMateria <br /> ;Well Destruction ❑ Well Diameter ' l (top 50') <br /> r <br /> Depth Filler Mhaterial (Below 50') <br /> No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITffION U { .� ; available within 200 feet.) „ <br /> E installation will serve: Residence _ <br /> CO <br /> mmercial'`�il Other <br /> Number of bedrooms I�' Lot size <br /> Number of living units: ` Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments \ <br /> I� � \ <br /> ` SEPTIC TANK Type/Mfg <br /> 11 - Capacity s Method of Disposal ` <br /> I 1 PKG. TREATMENT PLT. ❑ Type/Mfg Property Line <br /> SEWAGE SYSTE14 Distance to nearest: Well �� 'Foundation,!g �,� <br /> DESTRUCTION - <br /> ,� '�-��Y,J Total'�l�ength/size # - <br /> LEACHING LINE U No. & Length of lines ��, - ' <br /> r 1 Foundation "Y Property Line _ <br /> wFILTER BED -- -� <br /> �� D.istance to nearest; Wel.l.,.... _.. <br /> Depth Size Ip Number <br /> i SEEPAGE PITS Property Line <br /> SUMPS <br /> Distance to nearest: Well SIM' Foundation <br /> . � iP <br /> {- DISPOSAL PONDS � <br /> PI <br /> f I I hereby certify that I have prepared this applicationMand that the work will be done in accordance with San Joaquin county <br /> h' <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies <br /> suehfmannerng: 111 as to becomeythat subjectntohworrkmant compensatlionwlawsfof California."i <br /> I permit is issued, I shall not employ any p "1"certify that in the performance of the work for which <br /> " yl.. Contractor's hiring or sub-contracting signature certifies the following: <br /> ` this permit is issued, I hall employ persons subject to workman's compensation laws of California." <br /> y Se S <br /> inspectians.l Complete dr g o Dat <br /> The applican st all or all I A , <br /> p I Title: <br /> r } Signed X { ❑ <br /> [ F0M NT E ONLY +/ 5tk 466-6781 <br /> Area <br /> �a-� pplication Accepted by Lodi 369-3621 <br /> .h <br /> Additional Comments: Date L] Manteca 823-7104 <br /> E Pit or Grout inspection by i4 Date Tracy 835-6385 <br /> € �—-- <br /> i Final Inspection by <br /> s Appy nt - Return all copies 201 <br /> to: Environmental Heali�th Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, St k., CA 95 <br /> FEE BASE RM011NT DATE <br /> REMITTED RECEIVED BY <br /> PERMIT NO. <br /> AMOUNT UE (yam <br /> p <br /> INFO <br /> Ilot io/B2"50_.o'_ <br /> r c " <br /> !, .. EH 13-24 REV; I0/ /"[9 �/I�JCCTrb7 _ 4f _ _ _�'�k �w •�� _ - -•— -. <br />