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APPLICATION FCR.PERMiT z <br /> ti SAN JOAQUIN LOCAL H 3 <br /> HEALTH DISTRICT PERMIT NO. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209),466-6731 I DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br /> (Complete in Triplicate) <br /> rein <br /> an <br /> Application is hereby made to the San <br /> oiliancelwithlSanDJoaquin CountypDrdinanermitocecNo. 549tfor dsewage sorlNoth1862rforewell/pump <br /> incam <br /> described. This application is made P <br /> and the Rules and Regulations t an J uin Loca Health istrict. <br /> xvision Name <br /> J Job Address 'Phone <br /> Address <br /> Owner's Name No. _ Phone <br /> Contractor's Name <br /> a <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 0 DESTRUCTION U �, <br /> PUMP INSTALLATION SYSTEM REPAIR {� OTHER U <br /> SEWER LINES 10 <br /> DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: STANK AGRICULTURE WELL OTHER SJELL PITS/SUMP$ <br /> ^� <br /> FOUNDATION .f <br />` CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Excavation <br /> Industrial U Open Bottom ❑Manteca . <br /> U Domestic/Private E] Gravel Pack <br /> Tracy �4 Dia. of Well Casing <br /> a <br /> Public Other Delta Type of Casing <br /> V Irrigation Approx. Eastern * J Specifications <br /> Depth �-^ pepth of Grout Seal <br /> Cathodic Protection ' G <br /> ❑Geophysical Type of Grout r <br /> Surface Seal Installed by V <br /> LJ Other .__ ."" #� <br /> � State Work�Done <br /> ` Repair Work'46ne G Type of Pump ) Y <br /> k <br /> Well Destruction U Well Diameter Sealing Material (top 50' <br /> Depth Filler Material (Below 50') <br /> � f <br /> 1 <br /> available within 200 feet.) <br /> (ATION El REPAIR/,4DDITSON (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTAL <br /> installation will serve: Residence Commercial _ 0Cr <br /> Lat size i <br /> umber of bedrooms - Water table depth <br /> Number of living units: _ - = -- <br /> Character of soil to a depth of 3 :fee Capacity — No. Compartments <br /> SEPTIC TANK U Type/MfgT Method of Disposal <br /> = <br /> � PKC. TREATMENT PLT. � Type/Mfg Capacity Foundation, Property Line <br /> SEWAGE SYSTEM Distance to nearest:kt Well <br /> DESTRUCTION ` } �Q <br /> ` .�. Total length/size <br /> LEACHING LINE No. & Length of lines ` ® Property Line . <br /> II FILTER BED � Distance to nearest: Well f_�� <br /> oundation <br /> F DepthR� $1Ze + Number <br /> , <br /> SEEPAGE PITS � Foundation Property Line <br /> SUMPS � Distance to nearest: Well � x <br /> i - a <br /> DISPOSAL PONDS L� <br /> i <br /> plication and that the work will be done in accordance with San Joaquin county <br /> I hereby certify that I have prepa-red-this app <br /> I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature cersonor which this <br /> lin suchfman�ernas to becomecertifysubject that ntohworrkman� compensationwlawsfof California." <br /> permit is issued, I shall not employ any phe <br /> Contractor's hiringor <br /> Isub-contracting <br /> b-c ntractingpsignatureons sect;toes tkman'slcompensationrlaws ofaCalifornit .in the gerformance of the work for whit <br /> this permit is issued, m Tete drawing on reverse side. <br /> ��- pate: <br /> The applican must call f r ll re ed inspection Title: -_ - <br /> Signed X <br /> D�RTM NT'USE ONLYNT'USE ONLY ' Area $tk 66-6781 <br /> Application Accepted by Lodi 369-3621 <br /> Additional Comments: 4 Date �' ��� Manteca 823-7104 <br /> Pit or Grout Inspection by pate L7 Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> RECEIVED BY DATE PERMIT NO <br /> FEE ;ASE AMOUNT DUE AMOUNT REMITTED J2INFO 3 <br /> 10/82 500 <br /> EH 13-24 REV. 10/92 <br /> 14-26 <br />