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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.. STOCKTON, CA <br /> I 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 andlor install the'-Work herein described:This application is.. . <br /> r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 7862 for welt/pump end the Rules and Reputations of the San Joaquin <br /> k Locaf Health District. <br /> City Lot Size IQ�+ PM <br /> Job Address <br /> moo s� - <br /> _�qZ,4 ,/j, �_ Phone <br /> Owner's Name Address — ... <br /> coritiactc _ Address �—License 14one <br /> WELL REPLACEMENT ❑ DESTRUCTION U <br /> TYPE OF WELLiPUMP: NEW WELL ❑ <br /> PUMP INSTALLATION CI <br /> REPAIR 0 OTHER CJ <br /> ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ;i <br /> FOUNDATION, AGRICULTURE:WELLOTHER WELL PfTSISUMPS <br /> INTENDED USE TYPE OF.WOLL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Bottom .0 Manteca 4 <br /> f Well Excavation Dia.of Well Casing <br /> Q Industrial ❑Ori <br /> ! T of Specifications <br /> {I Come 0 Gravel Pack ❑Tracy <br /> Type � T o}Grout § <br /> d i"1 Public. 1 1 Other (-I Delta Depth of Grout Seal Type <br /> c } I luigafion Approx. Depth t I Eastern Surfaco,Sealr Installed by <br /> sH'.P:' — Stale Work Pone <br /> i I Repair Work Done f3 Type of Pump ' <br /> Well Destruction ❑ We Diameter Sealing Material Itop 50 <br /> 1 <br /> Depth Filler Material(Below 50;1 <br /> 7ypE OF SEPTIC WORK: NEW INSTALLATIO REPAIRIADDITION DESTRUCTIVN I i (No septic system permitted it public sewer p <br /> available within 200 feet.) t , <br /> iSys <br /> installation will serve: Residence Commercial Other <br /> Number of ElVing units: - Number of_bedrooms_ <br /> Wi <br /> Is <br /> e. <br /> Water table depth <br /> LrC� Character of soil to a depth of 3 e t' <br /> 5� dx ANK ❑ Ty <br /> '. .. palMfg Capacity No.Compartments <br /> SEPTIC T " x _ <br /> Method Of Disposal <br /> 0 PKC.TREATMENT PLT.❑ _ l ltentt "i Vt <br /> Foundation Property Lina' a r •1 ,+��NF' , <br /> e fit "Distance to nearest: <br /> well <br /> 4otal len�tlllsIre b V f <br /> LEACHING LINE. No.&Length of lines r <br /> y .. l" ouadation Property Lina S r <br /> FILTER BED ' Distance to nearest: Well�> ',4; <br /> r <br /> _ •�yif',id �..r�� - Ntimbar <br /> 'SEEPAGE PITS I I Depth `��Sixe <br /> ^r <br /> tE <br /> Sumps.,; L7 Distance to nea+est: Well Foundation Property Line <br /> is ti g a DISPOSAL'PONDS ❑ ' <br /> !hereby[artily that I have prepared this application and that the work will be done in accordance with San Joaqu{nxc¢unty ordinarteas ratrna lativa and <br /> j <br /> rules and regulations of the San Joaquin Local Health Dihirict. <br /> f cartil that in <br /> owner or Jcensed agent's signature certifiethe performance of the work lar whitfi this ptxrrlkt b isetfOd,f aftall not <br /> fin,;, Homa s the following:" Y <br /> employ arty person in such manner as to become subject to worxman <br /> ue's compensation laws of California,"Contractor's hiring orsu�twtt[tatttnp aipnatum" <br /> ca ti[ks tF a following:"i certify that in the performance of the work for which this permit is issd,)ahell employ persons subject to worttrnena compenaa <br /> .tlaI laws of California." <br /> ? The applicant must ca11 for II required'inspections. Complete drawing on reverse side. <br /> v y <br /> 5 % Title ��':- ••' Date <br /> lgned <br /> FO PARTMENT USE ONLY ? �/ <br /> a z� r paleArca <br /> ' Fa Application Accepted by p <br /> t " r Date Fina'inspection by Dete�J <br /> ° Pit or'Grout Inspection by r i <br /> Addrtlonif Cornmenta: i <br /> "-i ❑Stk 466.6781 ❑ Lodi 36.4-3621 t7 Manteca ,82 f-7104 - ❑Tracy-tE35 8385 <br /> rt <br /> ° :, Applieent Return ail oopies to: Environmental Health Permit/Services 1601 E.Hazelton Ave;; P O Box 2009 Stk,CA 96201 x; <br /> v 1 <br /> FEE AMOUNT DUE 'AMOUNT RENl1TTEC CASH RECEIVED BY BATE` PERMR NO t <br /> T a INFO __ .—_....— "---.•. b-,..i <br /> + <br /> o <br /> •�EM 17.24 tREV.i��al <br /> • fN 142e ^ - <br /> - � ` y - �y>,. ..,,...:,x- +a'.wWr. .StS,..:i•{wrttG.t:-�i3+i�}" "�cP.+�__. <br /> " j .__ _ ..-...-..---•- .ri a..r-,�._.F,.,... ,au,a..-tl-.ivfi.r�:s»-vr`,....-,,ti-..rwt��5.'...7,.'s<s''.f Via,-rd... ..., <br />