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APPLICATION FOR PERMIT t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601E HAZEL—ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) lication is <br /> un Ordinance No.549 for sewage or Na. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the SanCJoaquin Local Health District for a permit to construct and/or install the work herein described. This app <br /> made in compliance with San Joagwn tY <br /> Local Health District. _ <br /> /, ��,jjjva �O�A �` City eN Lot Size <br /> Job Address iA b t> <br /> FC R n� <br /> k S Address .�`► <br /> Owner's Name Phone <br /> Q +� <br /> $01-ro y AVP— License No. 2_. —Phone <br /> CA"14R— Address �S� DESTRUCTION ❑ <br /> Contractor--fir-�— REPLACEMENT 0 , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ " SYSTEM REPAIR ❑ PROP. LINE <br /> SEWER LINESf'�3—fes—� DISPOSAL FLD. <br /> E DISTANCE TO NEAREST: SEPTIC TANK f , OTHER WELL PITSlSUMPS <br /> FOUNDATION ,+ AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Dia. of Well Excavation <br /> ❑industrial ❑ Open Bottom ❑ Manteca❑ Tracy Specifications <br /> Type-of Casing •- �-�� <br /> ❑ DomesticlPrivate ❑ Gravel'Pack Type of Grout <br /> (l Other ❑ Delta Depth of Grout Seal <br /> [1 Public Surface Seal installed by <br /> I I irrigation �..Approx. Depth t 1 Eastern State Work Done <br /> l e of Pump H.P. <br /> Repair Work Done ❑ Type Sealing Material Itap 50'1 <br /> Well Destruction L-1WellDiameter <br /> Depth Fib 'i <br /> Filter Material (Below 50 <br /> available within 200 feet.I <br /> TYPE OF SEPTlC WORK: NEW INSTALLATION I REPAIRIADDlTlON I.! DESTRUC11 TION I 1 fNo septic system permitted if public sewer Is <br /> Installation will serve: Residence� Commercial— Other �. <br /> Number of living units: Number of bedrooms F Nater table depth <br /> �. <br /> t Character of soil to a depth of 3 feet: LOAM ire Capacity �� No. Compartments <br /> SEPTIC TANK - ❑ Type/Mfg r <br /> [ Method of-Disposal <br /> PKG. TREATMENT-PLT. ❑ 1(�U �j _/ <br /> i Distance to nearest: Well <br /> l Foundation b Property Line .- <br /> f <br /> 0d r �oral length/size <br /> i LEACHING LINE f No. & Length of lines Foundation SLS— Property Line <br /> FILTER BED ❑ Distance to nearest: Well ; <br /> Number r <br /> SEEPAGE PITS IOr Depth 2 5r Size .T <br /> Foundation GU Property Line <br /> SUMPS LlDistance to nearest: Wel! <br /> El <br /> I hereby certify that I have prepared this application and that the work will-be-done-in-accDISPOSALIPONDS ordance-with-San Joaquin crium :�ordinances, state laws, and <br /> '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 fotor'which-this.iripermit is issued, 1 signature <br /> shall not <br /> nsation <br /> employ i s the following such <br /> certify that n the performance of he wok fot to workman r which this pe m t-is iss edlaws of 'floshall employ personsrsubject t workmanor 's compensa- <br /> te g: „ � <br /> tion laws of California." ' <br /> on reverse side. <br /> The applicant must call for all required �+spections. Complete drawing- 7 - <br /> 21- 81 <br /> Date: <br /> t/yr t' Title: <br /> Signed X <br /> } ' FOR DEPARTMENT USEk ONLY <br /> f �� S06 <br /> 3 ! Area <br /> y Date <br /> k Application Accepted by <br /> Final Inspection by Date <br /> Pit or Grout inspection by Date.-` <br /> Additional Comments: <br /> Cl Stk 466-6781 [1 Lodi 369 3621, -E] Manteca 823-7104 ❑ Tr Cy 835 6385 <br /> Applicant - Return all copies to: Environmen"tai Health Permit/Services 1601 E. Hazelton Ave <br /> ., P.O. Box 2009, 5tk., CA 95241 <br /> REEY DATE. PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED,• CASH <br /> INFO w <br /> + EH 1 <br /> 3-24 01 EV.I/K 51 � <br /> EH 14-2a <br />