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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA l � <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDLo `' <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 Ryles and Regulations of the San Joaquin <br /> 4 Local Health District. " Yl <br /> S r3 FUTURE HOME OF::. k—MART � Le � <br /> .. '*f.. �O <br /> Job Address­ G R A N T L I NE 4& TRACY ':BLVD..: i , City T R A C Y. •=Loi size PM <br /> Owners Name- PACIFIC ASPHALT , IN(Address P-,-O. BOX 7322 _ _STOCKTO.N � <br /> - Phone- <br /> f Contractor HENNINGS BROS . Address 3525 PELANDALEAAVE ' License No. 290813 Phone 545-1185 <br /> TYPE OF WELL/PUMP: NEW WELL t WELL REPLACEMENT 11 DESTRUCTION KI <br /> PUMP INSTALLATION `❑ <br /> SYSTEM rREPAIR ❑ �� OTHER ❑ �y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES v DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ' '" AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS >Aj <br /> f D Industrial ❑ Open Bottom Q Manteca Dia. of Well Ezcaiation i Dia: of Weil Casing <br /> El Domestic/Private ❑ Gravel PackTracy Type of Casing �� Specifications _ <br /> ❑ Public ❑ Other , ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ___Approx. Depth ffO Eastern Surface Seal Installed by <br /> Repair Work Done Q Type of Pump ' H.P. State Work Done it <br /> Well Destruction )U Well Diameter "h Sealing Material (top 50') j <br /> Depth Filler Material (Below 50') <br /> :k TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ❑ DESTRUCTION Q (No septic system permitted if public sewer is <br /> f ) <br /> Installation will serve: Residence_ Commercial— Other <br /> ' Number of living units:—_ Number of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. Q Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> { LEACHING LINE 0. & Length'of lines Toiai length/size <br /> FILTER BED <br /> El Distance to nearest: Wel! _. Foundation Property Line, <br /> SEEPAGE PITS Q Depth f Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 11 - —. <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, 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 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 for all required ' spections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> { F DEPARTMENT USE ONLY <br /> Application Accepted by �. Date �� u Area <br /> Pit or Grout Inspection by Date F rt T �f <br /> Final Inspection by Date <br /> Additional Comments: — <br />? ❑ Stk 466-6781 D Lodi 369-3621 E3 Manteca 823-7104 ❑ Tracy 835-6385 e <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201' 001 <br /> ` FEE AMOUNT DUE AMOUNT REMITTED x y <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br />{ -+ EH 13-24{REV.1 <br /> EH 14-28 •I® C?0 1S <br /> N <br />