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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES '1 YEAR FROM DATE ISSUED <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 described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address r of 11th St. & Banta Road city Tracy Lot Size PM <br /> Owner's Name R06ert Raspo Address P.O. Box 76, Banta, Ca 95304 phone 835-3785 <br /> Contractor NOACK PUMP CO. Address 4500 E. Fremont Stkn License No. 504513 Phone 948-8817 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION AX SYSTEM REPAIR ❑ OTHER ❑ <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 /> ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> XIX Irrigation _..Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump Turbine H.P. 50 State Work Done_Install turbine pump <br /> Well Destruction ❑ Well Diameter Sealing Material stop 501 in new well - 2001 setting . <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [.'I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is <br /> .—available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other �+ i <br /> Number of living units: Number of bedrooms E <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 1i1 <br /> I � <br /> LEACHING LINE ❑ No. & Length of lines f Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS I'I Depth size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ` <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, anc ^ <br /> rules and regulations of the San Joaquin Local Health Di§trict. 1 r <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 no <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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call or auired inspec to -Co Tete drawing on reverse side. <br /> Signed x DICK TAYL6k"lam` SALES/SERA ICED ate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byy� .(✓N�� ��l.Cdj/� Date O Area <br /> Pit or Grout Inspection by Date Final Inspection by Date f.Z <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK I <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> r.EH 13-24(REV.t/H 5) <br /> EH 14-29 <br />