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F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 26002 N. Pearl <br /> City Gait Lot size 33e 'X666 s fM <br /> Owner's Name Address <br /> 2714 <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP: NEW WELL 11 ZZ� Phone <br /> 462 1483: <br /> WI=LL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DTHER ❑ <br /> DISTANCE W*"*W&* ( *�� DISPOSAL FLD. PROP. LINE g% <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack 13 Tracy T Dia. of Well Casing <br /> *!F*r!***1c�4f * �r#i�A* j Ili****�R�F y of CasingSpecifications <br /> Ll Public <br /> ❑ IrrigationType of Grout <br /> `,q <br /> pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 {� <br /> Depth Filler Material (Below 50') A G <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EX REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is N <br /> available within 200 feet.) <br /> Installation will serve: Residence--.X- Commercial— Other <br /> Number of living units: _-17 Number of bedrooms _ ' <br /> Character of soil to"a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Adobe , . Compartments No <br /> 75 <br /> Capacity— i2 _ t <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well L20- Foundation„2 6 Property Line <br /> 64 <br /> LEACHING <br /> 4LEACHING LINE QA No. & Length of lines <br /> Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation 46 _ Property Line^,64 <br /> SEEPAGE PITS ❑XDepth 25 Size Number <br /> SUMPS ❑ Distance to nearest: Well _ <br /> Foundation Property Line _ t <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 county 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 for which this permit is issued, I shall not <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 Z,'.equired <br /> that in the perfo ante of the work for which this it is issued,I sha)!em Io <br /> tion laws of California." employ persons subject to workman's compensa- <br /> The applicant must call ins ns. Complete drawing on� <br /> Signed <br /> Title: <br /> 'De- <br /> FOR <br /> e: � <br /> FOR DEPARTM USE ONLY } <br /> Application Accepted y ` Date Area Ofj <br /> �Pit r Grout Inspection byDatInspection byy / Date <br /> e 7F-nal <br /> Additional Comments, -- <br /> ❑ Stk 4W-Ml -AzLodi 369-3611 ❑ Manteca 823-7104 ❑ Tracy 635- ; <br /> -Applicant-Return all pi to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,-P.O: Box 2009, Stk., CA 95201 r <br /> FEE. AMOUNT DUE AMOUNT REMITTED <br /> - INFO RECEIVED <br /> 'BY PATE PERMIT"N0. <br /> ca C- <br /> + E1413-24(REV.101M) <br /> Ot5 �S l-fit <br />