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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH ':DISTRICT �f�r q D a <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. r 1 <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1 ,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> l the <br /> rein <br /> Application is hereby adeotoithe San <br /> niJoaquin Loca ancelwli{thlSanth DJoaquin County t for a pOrdinance ermit to cNo. 549tfor dSewage sorlNo. 1862rfor ewell/pump <br /> described. This app <br /> and the Rules a Reg ations of the San Joaquin Local Health District. <br /> Subdivision Name <br /> JohRAddress Phone <br /> f Owner's;Name Address <br /> F i Phone r„ <br /> Contractor"s Name License No. <br /> 4 <br /> NEW WELL DESTRUCTION ~ r <br /> TYPE OF WELL/PUMP WORK: ❑ WELL REPLACEMENT; ❑. IU ! <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR" ❑ - OTHER` U PROP. LINE TQ. <br /> SEWER LINES D15POSAL FL D. <br /> DISTANCE TO NEAREST: _SEPTICITANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP€CIFICATIDNS <br /> Industrial ❑Open Bottom []Manteca <br /> Dia. of Well Excavation <br /> Dia. of Well Casing -~ -- <br /> F-IDomestic/Private ❑_� ay <br /> rel Pack[]_Tracy .�_- .�., :_~.•---- --�- - <br /> ❑ Public ❑ Other ❑Delta Type of Casing y <br /> LJ Irrigation Approx. Eastern <br /> ❑ Specifications <br /> Depth Depth of Grout Seal <br /> ❑Cathodic Protection f; <br /> ❑Geophysical Type of Grout <br /> ❑Other Surface Seal Installed by <br /> H p - State Work-Done- <br /> Repair Work Done Q Type of Pump <br /> ._ . :, �-- ---- 6- <br /> Sealing Material (top 50') ` <br /> Well Destruction U Well;Diameter <br /> Filler Material (Below 50') <br /> Depth - <br /> # TYPE OF SEPTIC WORK: NEW'INSTALLATTON REPAIR/ADDITION ❑ (No septic lank or seepage pit <br /> epublic availablermitted if feet.) <br /> 1 Installation will serve: Re idence Commercial Other <br /> Number of bedronns — Lot size <br /> Number of liking units:.. `- _�Wat"Water table depth <br /> Character of`soil to a depth of 3 feet: No. Compartments <br /> Type/Mfg. <br /> Capacity <br /> SEPTIC TANK =3 Method of Disposal <br /> Type/Mfg <br /> [ .� "" <br /> Capacity <br /> PKG. TREATMENT PLT. '- <br /> - -Foundation Property Line <br /> SEWAGE SYSTEM Distance to neare t."Well-.. <br /> $ DESTRUCTION _�� ~ " <br /> LEACHING LINE ' No>.& Length of lines �� <br /> `�� Total length/size, <br /> �y� �. Foundation Property Line <br /> FILTER BED ❑ N stance to nearest: Well <br /> 1 ' .Dept .,__/I Si ze . � <br /> Number <br /> SEEPAGE PITS /$'+2'_ Foundation Property;Line <br /> F Distance to nearest: Well <br /> F SUMPS LJ <br /> DISPOSAL PONDS ❑ yY <br /> hereby certify that I have prepared/thiis.app lication and that the work will be done in accord6nce with San Joaquin county <br /> 1 - <br /> I y <br /> ordinances, state laws, and rules and regulation's.,of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature cersonZin s'uchfmannnernas to become subjectthat ntohe performance worrkmanIs compensatilonwlawsfof California." <br /> permit is issued, 1 shall.not employ any p <br /> Contractor's hiring or sub-contracting er9onsusubject�toeworkman'slccompensationrlaws ofaCaliforniaerfarmance of the work far w is <br /> this permit is issued, I sh 11 employ p <br /> he a nt mus a or 11 quired inspections. Co pl•ete d i UY ,- <br /> Date: <br /> Title: <br /> Sign <br /> F DEPARTMENT USE ONLY\Area �� 4 Stk 466-6781 <br /> Application Accepted by E] Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection by Date 3 3 <br /> I 7 � Date L Tracy 835Stk., <br /> [ Final Inspection by � � <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 Alla el ton Ave., Box 2009, St k., CA 95201 <br /> sem' DATE PERMIT N0. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY � � <br /> INFO f ' <br /> R 10/82 500 <br /> EH 13-24 REV. 10/.82- (1 <br /> 14-26 <br />