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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'i YEAR FROM DATE ISSUED I <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> or No. 18&2 for we111pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage ! <br /> Local Health District. <br /> Stockton PM <br /> Job Address <br /> X81.6 East Morada Vane city Lot size <br /> X81..6 E Morada Lane Phone 931- <br /> 4883 <br /> Owner's Name Frank R. Ghilotti Address ' <br /> Contractor <br /> Clark Well Address 2'24 E Charter Way License No. 371..560 Phone7676 <br /> TYPE OF WELL/PUMP: NEW WELL a WELL. REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION F1 SYSTEM REPAIR EX OTHER C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> AGRICULTURE WELL OTHER WELL ' _P1_TS/SUMPS <br /> T INTENDED USET TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of CasingSpecifications <br /> ❑ Domestic/Private 1-1GravelPack ❑ Tracy yP <br /> ['1 Public I--] Other <br /> CI Delta Depth of Grout Seal Type of Grout <br /> _ <br /> 1 1 Irrigation -Approx. Depth t I Eastern Surface Seal Installed by replaced <br /> Repair Work Done ❑ Type of Pump �� H.P. <br /> State Work Done _� <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material 16elow 50 —� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION I I (Noavasepticlable system <br /> in rented if public sewer is D' <br /> Installation will serve. Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PCT.'dNo. Compartments <br /> l _ _• ,-_ Method of Disposal <br /> " • <br /> -Distance-to-nearest: Well Foundation Property Line <br /> :z <br /> I LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> l Property Line <br /> FILTER SED ❑ Distance to nearest: Well Foundation p Y <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS S L1 •+Distance-to nearest: Well Foundation Property Line <br /> DISPOSAL-PONDS- — ❑ — _ - " ' <br /> I hereby ce y hat I (lave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and r ulat ons of th Joaquin Local Health District. <br /> Home own r or I tensed ent's ignature certifies the f lowing: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> employ an per n in suc mann r as to a subje to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the oil wing:"I rtify t in a rmanc f the work for which this permit is issued, l shall employ persons subject to workman's compensa <br /> tion laws of forma." <br /> The appli u t call all r ire i ns. mplate drawing reverse side. 1/ti 5/89 <br /> Signed X <br /> Title: Sec—Tres Date: <br /> DEPARTMENT USE ONLY <br /> 1 Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104'- ._❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> +.EH13-241REV.i/r•5Yis <br /> EH 1446 <br />