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APPLICATION FOR PERMIT <br /> C r� SAN JOAQUIN LOCAs. HEALTH DISTRICT <br /> 1 i 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> y� PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complote in Triplicate) <br /> Application is hereby made to the San Joaquin or No. 18 <br /> Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made a compliance with San Joaquin County Ordinance No.549 for sewage 62 tar wetr/pump and the Rules and Regulations of the San Joaquin <br /> in <br /> Local Health District. <br /> City Lat Sire PM <br /> Job Address �/ 4V 1 <br /> tijz/d <br /> i SIL p�j J /i lis _ Address #4 - Phone 3 <br /> Owner's Name �. <br /> Z Phone / <br /> Contractor <br /> Address � `"� License No_�...� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DfSTRUCTION D <br /> PUMP INSTALLATION fl <br /> SYSTEM REPAIR 0 OTHER <br /> DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELL PITS/5Uf41PS <br /> fOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dom. of Well Casing <br /> L7 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation <br /> T of Casin Specifications <br /> FJ pomesticlPrivate Q Grovel Pack ❑ Tracy Yl� T of Grout — <br /> f"'1 Public Ll Other n Delta Depth of Grout Seal Type _ <br /> 1 irrigation —Approx. Depth 1 I Eastern Surface Seal installed by <br /> of Pump H.P. State Work Done <br /> Repair Work Done i-] Type �1 <br /> Well Destruction 0 Well Diameter Sealing Material Itop 501 <br /> Depth Filter Material IBeiow 501 -- O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I I DESTRUCTION I t IINoo septic System lable within 200 permitted if public sewer is -rte <br /> �. IrtstaMation vA serve: Residence— Commercial— Other F2 —-- <br /> Number of living units: Ste_. Number of bedrooms <br /> Water table depth <br /> Character of so9 to a depth of 3 feet: r <br /> SEPTIC TANK fl Type/Mfg <br /> Capacity___— No, Compartments <br /> PKG. TREATMENT PLT- a Method of Disposal <br /> Distance to nearest: Well Foundation Property Line. <br /> LEACHING LINE L1 No. b Length of lines I — E�� Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation /ZV ' Property Line — <br /> SEEPAGE PITS I Depth :Z Size r Number <br /> SUMPS Ll Distance to nearest: Welt_`^.� Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the <br /> rules and regulations of the San Joaquin Local Health Datrkt. <br /> "I certify that in the performance of the worik for which this permit is ieaclin I shag <br /> not <br /> Home owner or licensed agent's signature certifies the foYowing: ure <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature <br /> certifies the following: 1 ce that in the performance at the work for which this permit is issued,I shall employ persons subject to workmen's compensa- <br /> tion taws of Calif <br /> The a must call for uired ns. Complete drawing on reverse side. <br /> Signed Title:' Date: <br /> FOR DEPARTMENT USE ONLY r� <br /> Application Accepted by Date —' 2- Area <br /> or Grow Irvpection by DatarG Final Inspec dot by -�J Dam <br /> (Additional Comments: 14 -�rC 6f �(• . <br /> ID Stk 468-6781 0 Lodi 369.3621 © Meineke 823-7104 l3 Tracy 835.6385 <br /> �.. Applicant - Return all copies to: Environmental Health Permit/Services IWI E. Hazekon Ave., P.O. Box 2009, tk., CA 55201 <br /> FEE AM04JNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'NO. <br /> INFO <br /> • EN 13.74 WEY.7 RI <br /> ,tea <br /> EH 7476 <br />