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of i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA + <br /> R Telephone (203) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No 1B62 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 29555 E. Oran a Ave . City Esc al on Lot Size PM <br /> Owner's Name Manuel de CASTRO Address 1881 FOOTHILLS CT. Oakdale Phone 847-2126 <br /> Conhacta f rnpr frtrt Address License No- a-h-4411366Phone" A 4 7- <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL,REPLACEMENT ❑ DESTRUCTION C7 <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER D <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 2 Industrial EJ Open Bottom Cj Manteca Dia- of Well Excavation Dia. of Well Casing , <br /> ❑ Domestic?Private Ci Gravel Pack ❑ Tracy Type of Casing Specifications {� <br /> r-i Public 17 Other F l Delta Depth of Grout 'Seal Type of Grout <br /> I i Irrigation — Approx. Depth I I Eastern Surface Seal Installed by I a <br /> Repair Work Done LJ Type of Pump H.P. State Work Doric <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Materia! (Below 50') -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONxtXix REPAIRiADDITION I 1 DESTRUCTION I i (No septic system permitted it public. sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence% Commercial— Other <br /> Number of living units: 1 Number of bedrooms_ 3 <br /> Character of soil to a depth of 3 feet: sand ,rock, Clay Water table depth + <br /> SEPTIC TANK TypelMfg P & L Concrete Capacity 12 0 o Na. Compartments 2 <br /> PKG. TREATMENT PLT.'❑ Method of Disposal 1e a C h 1 n& 5 u 91 <br /> Distance to nearest: Welt I Foundation 10 Property Line <br /> LEACHING LINE ON No- 8 Length of lines 2 @ 75Total length/size 3000 Sq .ft . jro� <br /> FILTER BED 0 Distance to nearest: Well 115 foundation 30 r Property Line 22' t <br /> SEEPAGE PITS �; Depth 2.5 Size 3 3" Number 2 <br /> SUMPS U Distance to nearest: Well 165 Foundation An Property Line 24' <br /> DISPOSAL PONDS ❑ <br /> E <br /> I hereby certify that I have prepared this application and that the work wfli be done in'accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." -- ------- <br /> The applicant ust all fpr re -ed inspections. Complete drawing on reverse side. <br /> Signed XTitle: Date: <br /> EPARWENT USE ONLY I <br /> Application Accepted by . 41QAO% I, <br /> Date ,o` Area <br /> Pit or Grout Inspection by Dale _. Final Inspection h _ Date/z <br /> 01 <br /> Additional Comments: <br /> ❑ Stk 466-6781 G Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services IWI E- Hazelton Ave., P.O. Box 200k Stk., CA 95201 ° <br /> FEE AMOUNT DUE AMOUNT REMITTED ICK S AtCEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . H3 �a1�>_v.t,M" 114 6­0 � .a 0 -koe � Co-3c�—�� ga --£3 3 " <br />