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} <br /> t APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application is ftereby made to the San Jou^uin 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 tg— (` <br /> Local Health District. �} <br /> / City <br /> lot Size PM <br /> Job Address f Rd �t®C or0 <br /> Phone <br /> Address <br /> Owner's Name <br /> LicenseCo. Phone <br /> 1/1 Address <br /> Contractor LL REPLACEMENT O DESTRUCTION ❑ <br /> TYPE OF WELL/PU P: W WELL O OTHER [°f <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES �------ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION ______--- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing <br /> O Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> O Domestic/Private O Gravel Pack O Tracy Depth of Grout Seal Type of Grout — <br /> 6'1 Public <br /> fl Other do Delta _ <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> State Work Done® — <br /> of Pum H.P. <br /> Repair Work Done L3 Type p Sealing Material(top 50'! <br /> Well Destruction ❑ Well Diameter Filler Material(Below 50') <br /> Depth permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I 1 DESTRUCTtQN I 1 avalable v�system <br /> feet.) <br /> Installation will serve: Residence— Commercial` Other <br /> Number of living units: Number Of bedrooms �� Robert Fourt <br /> Eu� senior Geologist <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg R® ENTALMANAGEMENT INC. <br /> PKG. TREATMENT PLT.O Foundation_ 2141 Mono Way <br /> Distance to nearest: Well 26M Braden#178 <br /> Modesto, P0. Box 3905 <br /> O Callfornla 95370 <br /> Foundation California Sonora, <br /> ( 526.9284 <br /> LEACHING LINE No. &Length of lines dation- (209)532-0361 <br /> FILTER BED ❑ Distance to nearest: Well FAX(209)532-0773 <br /> SEEPAGE PITS I I Depth S1%e SITE INVESTIGATIONS • HYDROGEOLOGY • PERMITTING <br /> __ <br /> Foundation_ __ _.. .__------.------ <br /> SUMPS Ll Distance to nearest: Well i 1" _ <br /> DISPOSAL PONDS ❑ <br /> I 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. that in the pert of the wor for which this permit is issued, I shall not <br /> nt's signature certifies Horne owner or licensed ages the f I ng: rdfYof <br /> employ any person in such manner as to become subject to workman's compensation laws Of California.*'shllemploy <br /> persons <br /> subject <br /> � o worktman'sgsignature <br /> compensa- <br /> certifies the following:"I certify that in the performance of the work for which this permit is' ,I shall empty pe <br /> tion laws of California." <br /> The applicant mu call f all requir d inspections. Complete drawing on rev rse side`. <br /> Title: Date: A <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by <br /> _ Final Inspection by ®ate <br /> ti <br /> Additional Comments: Ta <br /> ❑ Stk 466-6781 O Lodi 36.^,-3621 O Manteca -7104 <br /> Applicant- Return all copies to: Environmental Haelth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO ems„ f rf 7„- <br />