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09/20/2004 10:18 464013 ENVIRONMENTAL ITH PAGE 06 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplete in Triplicate) <br /> tor <br /> all the Work herein <br /> cribed. This <br /> cation is <br /> Application <br /> ce weby iade 10 the th h S n Joaquin County Ordnance No.549 lot sewage or uin Local Health ojstriet for a permit <br /> No. 1962 forcwel/dpump end the Ru et andRegulations of he San Joaquin <br /> Local Health District. ,a ^ <br /> Job Address <br /> a`-36D�_$ if91 C.F/1 K(� _ City _— lot Size PM <br /> �e, Q,�) Address S ��d Phone _.— <br /> Ownci s hams ���-�y (/, <br /> �J,J fop 97S Lice No. -3 f'P F Lis 2.— <br /> Contraclor,�;eftiLPLL _ Address 4-20 <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTIO <br /> PUMP INSTALLATION L1 SYSTEM REPAIR fl OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ — DISPOSAL FLO. PT SP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL , <br /> UMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> _ _ Die. of Well Casing <br /> L) industrial LU Open Bottom (5Manteca Die. of Well Excavation Specifications <br /> CT Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing <br /> I Delta Dept al GfOrd Seal Typo Of Grout <br /> M Public fl Other _ <br /> I I hri0ation _...-.Approx. Depth I I Eastern Surface Seal Installed by <br /> __ H P State Wok 00" _ <br /> Repair Work Done U Type of Pump _ gErz/I <br /> Well Destruction Well Diameter _2Lua1— Scaling Material (top 60 <br /> Depth p y; Filler Material IBeIOW 50'1 - V <br /> ryPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INallableD Septtic thin 20Farm'"" <br /> rm" tl if public sower is O <br /> Installation will serve: Residence _ Commercial_ Other <br /> Number of living units: . Number o1 bedrooms <br /> Water table depth r'1 <br /> Chsncter of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK 0 Type/Mfg ., Capacity. <br /> Method of Disposal <br /> PKG, TREATMENT PIT.CI Property Line <br /> Distance to nearest: Well Foundation_ y <br /> fl No. 6 Length of linea Total length/size <br /> LEACHING LINE 9 Property Line <br /> FILTER BED CI Distance to nearest: Wall-.. Foundenan .,__— <br /> ---size Property— Number <br /> SEEPAGE PITS I I Depth __ <br /> SUMPS LI Distance to nearest: well _-- Foundation-- ProoertV Line <br /> DISPOSAL PONDS L7 <br /> I hereby cenily that I have prepared this application and that the work Will be done in accordance with San Joaquin county grtlinances, state laws, an <br /> rules end regulations of the San Joaquin Local Health District. <br /> not <br /> Home owner or licensed agent's signature anifias the following: "I certify that in the pe <br /> ltoof California."ncthe work lot which this Dermic is issued,I aha ure <br /> emplcert Io y the personin such <br /> cemanner <br /> at to come subject <br /> t she work workman's <br /> compensation <br /> eh this pe maws iss edfI shall employ persona subjecring t to workman's ccempensa- <br /> following: <br /> tion laws of <br /> The applicant m t I to Ired Inspections. Complete drawing '1rroveersee a�iidde. <br /> Title:ry' Data: <br /> Signed X <br /> OR DEPARTMENT USE ONLY <br /> Area <br /> Dais Q � <br /> Appucstlon Accepted by e Data/U-Pb-I0c(" <br /> Date Final Inspection by <br /> Pit or Grout Inspection by f <br /> Additional Commonta: <br /> ❑ Slk 466.6701 ❑ Lodi 369.3621 ❑ Manteca 623-7109 d Tracy WS-SUSO. BOK ZD09, Sik., CA 95201 <br /> Applicant- Return ed Copies to: Environmental Health Permit/Sarvieaa 1601 E. Hnnion Ave., P. <br /> FEE AMOUNT DUE AMOUNT REMITTED C RFceWEp av DATE PERMIT NO <br /> 11 <br /> INFO 1O <br /> . fM ts7s IaEv, r x v <br />