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6 <br /> :,. APPLICATION FOR PERNiiT <br /> lf' _ <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 F. >)A7_EL s ON AVE., STOCKTON, CA <br /> ➢,^- "ori <br /> Telephone 12091 466-E7$1 <br /> PERIMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Xomplete in Triplicate] <br /> ' Application is hereby maje to the San Joaquin Local Health District for a permit to construct and/or instalr the work trftein described.This application 63 <br /> A 1 made in compliance with,San Joaquin County Ordinance No.549!or sewage or No.1867 for welUpump and the Rules and Reputations of the San Joaquin <br /> Local Health District. <br /> �7 / <br /> Job Address �� / (p �w r,�^.R 4 — City C "A91 Let Sizey x 32p PIPE <br /> — i <br /> rid �r 1 a a h �f Address <br /> b C�+ti•ner's Name�i S�—� r�---. --�a7�a_Z�— Phone <br /> C-ntractor 4 U� _Address License No. Phone <br /> ' TYPE OF WELL1PV11P: NEW WELL 0 WFLL REPLACEMENT C! DESTRUCTION ❑ <br /> ;9 f PUMP INSTALLATION C SYSTEM. REPAIR L] OTHER 0 <br /> -• - , DISTANCE TO NEAREST: SEPTIC TANK ______ SEWER UNIE5 _ DISPOSAI-FLD.---_ PROP. 1.114E � <br /> 5 r — FOUNDATION _AGRICULTURE WELL OTHER WELL _ PITS/SUMPS r <br /> INTENOED USE TYPE OF WELL PROBLEM A.9EA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open BaGom a Manteca Dia. of Well Excavation _ Dia-of Wel Casing <br /> ..... f'. <br /> Q ❑ Domessico <br /> 'Private C Gravel Pack C.Tracy Type of Casing Specifications <br /> `/`�'^n- arc?H•-""'a' 4a Public C Other E; Delta Depth of Grout Seal --. Type of Grout <br /> lnigatior, ---Approx. Ce h _! Easterri Surface Seal Insia;i4d by_ <br /> i <br /> r <br /> Repair Work Done F1Type cf Pump H.P. State Work Done <br /> s Welf Destruction 7 Well Diameter Sealing Material{tap 50') <br /> 7 <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C; REPAIR/ADDITION❑ DESTRUCTION Li (No septic system permitted if public sewer is <br /> available within 200 feet.) - - <br /> 'L�'Y•�fe - - Installation will <br /> serve, Residence.� Commercial : Other <br /> t f Number of living units: <br /> Number of irz_droems�z^ / r <br /> Chwacter of soil to a depth of 3 feet: !7 h Water table depth d <br /> c ; <br /> SEPTIC TANK TypelMfJ — Capacity:2 _ No. Compartments : <br /> PKG.TREATMENT PLT.,-7- ) Method of.Disposal <br /> Distance to nearest: /•Nell�!�._=_ Foundation �� Property Line— <br /> y � LEACHING :_IN-F No. &Length of lines •���� � --- 'oral leng" ;size /yo _ <br /> r <br /> FILTER BED Distance to nearer..^. Well ' <br /> Foundation. _ Property Line — <br /> ',F K SEEPAGE PITS C° Depth __—Size_�..«.�, Number <br /> „t SUMPS C' Mlizan:e to n_-erest Well�.. _ FoOndatien_ Property Line <br /> DISPOSAL PONDS ❑ <br /> T <br /> r I heteby certify that I have prepared this appiicai on and;'tat the wark will he done in accordance with San Joaquin county ordinances,stare laws,and <br /> ., riles and regulations of ine San Joaquin,Local Pe4ftzh Oisirict. <br /> Hone owner or licensed agent's signaterre certTies:the fdtawing:"I certify that in the perfom,ance of the work for which this permit is issued,I shall not <br /> employ any:.2rson in such manner as to becorne subject to workman's coir-Pensanon taws of Caiifomia.•'Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this F.ermit is issued,I shall employ p.rsons subject to workman's compensa- <br /> rs-- tion laws of Califomia." <br /> applicant must call for all required inspections.Complete drawing on rersrs^_side- <br /> The <br /> Signed Title: `� � � Date: r� 96 <br /> i� �-�— <br /> ^L FOR DEPARTMENT USE ONLY <br /> A li anon Accepted by F–� Date d area O I <br /> PP <br /> ., Pit or Grout Inspection by r` lr� D^te Final Inspe:t;on by <br /> Add'+t;onal Comments: <br /> L] STk =.66-"1 71 Lodi 3M3621 G Manteca 8.23.7104 ❑ Tracy-83F_6M <br /> Applicant- Return all copies to:Environmental Health Pomtit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> •' FEE AMOUNT DUE A!.!OVNT RTTE <br /> EMID CASH RECEIVED BY DATE PERMiT'No. <br /> S r _ t1:Fp <br /> S <br /> Ey 1324 IaE <br /> E" <br /> V. ss�' u. 1 <br /> C <br /> ♦ T <br /> rLr i+.r5 <br />