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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601 E. HAZELTON AVE., STOCKTON, CA ' <br /> Telephone 1209) 466-6781 . , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> cawn <br /> Application is hereby made to the San Joaquin Local Heatth District for a pe or 1No 1(362 fort to cweil/d/ump and the Rules and or install the work (Regulations of the San' qu's <br /> P u7 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage ' ALI C/Local Health District. <br /> r .� <br /> Ci �Y Lot Size�y/It7� PM <br /> Job'Address yA cy <br /> �i � Phone 3 --3 gs� <br /> Owner's Name �� ' f f/v C% Address <br /> . . Phone <br /> Contractor's Name _ _J� ✓ License No. <br /> NEW WELL f "WEL1 REPLACEMENT DESTRUCTION <br /> TYPE OF W"cLLlPUMP: ..•POTHER ❑ <br /> UMP INSTALLATION � SYSTEM REPAIR C <br /> SEWER LINES DISPOSAL FLO. PROP. LINE -- <br /> DISTANCE TO NEAREST: SEPTIC TANK _ —OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE,WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_SRECIFICATIONS <br /> Dia. of Well Casing <br /> Industrial i .1 Open Bottom M Manteca Dia. of Well Excavation <br /> _ Specfications <br /> C Domestic/Private Gravel Pack Tracy Type of Casing__ <br /> El Public - Other <br /> _ Data Depth of Grout Sea'. Type of Grout—_ <br /> = Irrigation _Approx. Depth 11 Eastern Surface Seal installed by <br /> H.P-_ — State Work Done N <br /> Repair Work Done Type of Pur^p / <br /> Well Destruction 1 Well Diameter Sealing Material itop 50'1 r <br /> Depth Filler Miterial iBelow 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION C DESTRUCTION iNailabe septicamwithin (earthed if public sewer is CJ <br /> Installation will serve: Residence L Commercial Other - <br /> Number of living units: Number of bedrooms_ L2 r f- <br /> JA�t/ /-1-1 <br /> 0� Water table depth _ <br /> Character of soil to a depth of 3 feet: _. No Compartments <br /> SEPTIC TANK i Type/Mfg Pic C,4 Capacity <br /> Method of Disposal <br /> PKG.TREATMENT PLT. 11 /2 , <br /> D'�sYance to nearest:• We4 Line/� � Property Le , <br /> LEACHING LINE x No. & Length of lines <br /> -��Pe' ./ /r'/� Total length size 170, <br /> Distance to nearest: Well Foundation /O" Property Line <br /> FILTER BED --�--"`T <br /> SEEPAGE PITS C Depth _ /� .Size f.X f/���0 Number - <br /> SUMPS F. Distance to nearest Well c _ — <br /> Foundation Property Line ' S <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 /> rubs and regulations of the San Joaquin Local Health Dist'ict. <br /> Home owner or licensed agent's signature cert les the following: "I certify that inthe <br /> laws of ance of the Contractor's work <br /> for <br /> orwhich gi smarm-conitssued, signature <br /> not <br /> employ any person In such mannor as to become subject to workman's compensa Issued,1 shall employ persons subject to workman's compensa- <br /> cert fles the following:"I certify that in Ove performance of the ws work for wh,ch th permit is <br /> tion laws of California." <br /> The applicant must pall for all required inspections. Complete drawing on reverse side. <br /> Tale: Date: <br /> Signed x r 1>' l -- <br /> /FOR D ARTNIENT USE ONLY O <br /> f G., Date Ito6 {_Area- <br /> Application <br /> Application Accepted by �Q`Ifs <br /> Final In action by Data <br /> Pit or Grout Inspection by Date „/ - <br /> Additional Comments: <br /> -.N, /0-1, �/ ? "�7 <br /> ❑ Stk 46&6781 ❑ Lodi 389-3621 ❑ Manteca 673-7104 ❑ Tracy 8368385 <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 96201 <br /> CK t RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 1312 (REV 1o'87( <br /> EH 14-26 ..� <br />