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n <br /> u APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> ]PERMIT <br /> Telephone (209) 466-6781 <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) applicationribe . This is <br /> Joaquin Local Health District for a permit to construct ell pu <br /> and/orinstall and the Rules and rRegulationds of the San Joaquin <br /> n desc <br /> Application is hereby made to the San q <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wR <br /> Local Health District. <br /> 1 GRC 7� Lot Size z PM <br /> � �C c� � City <br /> -21 L— �ta9) _ <br /> Job Address c_ <br /> Phone <br /> �, Address <br /> Owner's Name <br /> .—Ay <br /> License No. Phone_ <br /> Contractor Address <br /> NEW WELL ❑ WELL REPLACEMENT'-❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: OTHER ❑ <br /> t >•PUMP INSTALLATION ❑ �. � - SYSTEM REPAIR D�......*++.�.-_��^ I <br /> SEWER LINES �� <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ±` OTHER WELL— <br /> FOUNDATION <br /> FOUNDATION �.—�— AGRICULTURE WELL <br /> TYPE OFIWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE —�� pia. of Well Excavation <br /> [D Industrial Ll Open Bottom ❑ Manteca Specifications <br /> 't y° ❑ Tracy Type of Casing <br /> I ❑ DomesticlPrivate El Gravel Pack :_ Depth of Grout Seal Type of Grout f <br /> Other n Delta _ <br /> 1-1 public F Surface Seal Installed by <br /> IIU <br /> 1 1 irrigation lk�._ApproK. Depth t:),Eastern t T State Work Done — 1A <br /> Type ' H.P. <br /> Repair Work Done ❑ yP of Pump. Sealing Material Stop 50'1 <br /> P <br /> Well Destruction ❑ Well Diameter x <br /> r,; Filler Material IBelow 501 <br /> Depth <br /> available within 200 feet.! <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION 1 11 REPAIR/ADDITION� DESTRUCTION l 1 ave(No septic system permitted it public sewer is <br /> Fa: <br /> Installation will serve: Residence . Commeria Other <br /> Number of living.units: Number of.bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: 1 Capacity la io a Noy Compartments <br /> SEPTIC TANK *' IQ Type/Mfg 10 Y Method of Disposal <br /> PKG, TREATMENT PLT. ❑ A Foundation �� Property Line__.!_— <br /> Distance to nearest: Well� 4 <br /> C ❑ No. &.Length of lines <br /> % .r/S ���/ Total length/size l � <br /> LEACHING LINE r Foundation .� erty Line <br /> FILTER BED ❑ Distance to nearest: Well �— <br /> MM- , � <br /> Size Number <br /> SEEPAGE PITS Il Depth ' <br /> f /SD Foundation A90 <br /> Property Line <br /> SUMPS Ll Distance to nearest Well <br /> DISPOSAL PONDS ❑ - "" ii <br /> F <br /> I hereby certify that! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> F rules and regulations of the San Joaquin Local Health District. ,r rformance of the work far which this perm[is iss <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the peued, 1 signature <br /> shall not <br /> Workman <br /> employ s the polfowingsulc errttiify that n the performance ofothe,wo k for which this permitnsation 4is issueds of ,fI shall employ persons subject ct t wr'&hiring or su corkman�scompensa <br /> cert - <br /> tion laws of California." P + <br /> The applic t ust ca or ired inspections. Complete drawing on reverse side. i f <br /> Date: <br /> Title: __0 <br /> Signed <br /> F. DE RTMENT USE ONLY <br /> Date Area <br /> oplication Accepted by Date <br /> Pit <br /> � Date Final Inspection by <br /> Pit or Grout Inspection by . <br /> Additional Comments: ❑ Tracy 6385 <br /> ❑ Stk 466-6781 f [2 Lodi 369-36214 + ❑ Manteca 823-7104 <br /> Iton Ave., P.O. Box 2009, Stk.. CCA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haz <br /> K RECEIVED BY DATE PERMIT NO- a .�� <br /> FEE AMOUNT DUE AMOUNT REMITTED d <br /> INFO <br /> � <br /> r.EH 13-24 IREV.I/H 51 d 3 <br /> EH 14-29 ;-y <br />