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01 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (203) 466-6781 " <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> (Complete in Triplicate) <br /> • Application s hereby made to the San Joaquin Loral Heal•h District for a perr.tit to construct and/of install the work he,ein described.This application is <br /> y <br /> made a complianceeieb with San Joaquin Cnunry Ord hence No.5a9 four sewage or No, lWi2 for wetturiu//mir,amt the Rules and Regulations of the San Joaquin <br /> .heal Health District. /,J6_ rY"� / PM <br /> Lot Sire i <br /> Job Address _ _ <br /> !r <br /> Phone��JJ��•'— <br /> Owner's Name _ <br /> v _License No. `s'+7? +Phone <br /> Contractor - _`�` to - cress ' IJ — <br /> NEW WELL ,i WELL RE°LACEPdEN1 LI DEST9UCTION LJ y <br /> TYPE Or WELL/PUMP: SygyL'Id REP(.IR G OTHER Cl <br /> PUMP INST\LLATION .7 y/ _ PROP.LINE ' <br /> _ SEW) LINE` _ DISPOSAL FLO { <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRIC I E WELL OTHER WELL PITS/SUMPS <br /> FOUNUATION -. <br /> INT' USE TYPE OF WELL PROIlLEM AR CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> Ll Industrial ❑Open Bottom r Manteca Dia.of Well Excavation Specifications <br /> Type.of Casing <br /> -- <br /> (j Domestic/Pnva:e ❑Gravel Pack I l D/to, <br /> Dell, Depth <br /> Depth nl Grout Seal Type of Grout_ — <br /> i I'1 Public 11 Other <br /> Approx. Depth I 1 Surface Seal Insrailed by <br /> 1 <br /> I I Innatinc State Work Done__— <br /> Repair Work Done U Type of Pump _ H'P' <br /> Seali g Material)top 50'1 <br /> 1 Well Destruction ❑ Well Diameter �L— a\' <br /> t <br /> Depth �/ Filler.Material 18eto 50'1 �J <br /> I TYPE OF SEPTIC WOFlK: NEW INSTALLATION' I Rl'PAIR/ADDI ZION 11 14 DESTRUCTION I I rivailablterw thin 200 feet.)ied if public sewer is <br /> Installation will serve: Residence— Commercial_. Other - <br /> Number of living units: Number of bearoo r Water table depth <br /> Character of soil to a depth of 3 feet: <br /> �(�Capacity_ _ No.Compertmenta <br /> SEPTIC TANK ❑ Typo/Mfg Method of Disposal <br /> PKG.TREATMENT PLT.❑ Property Line <br /> Distance to neer st: Well—__ t=�:'ndation _ <br /> III <br /> _ Total length/size !-- <br /> LEACHING LINE Ll No.&Length of lines / Property Line 5 <br /> p_ oundation.�Q_. <br /> FILTER BED O Distance to nearest: Well <br /> a � <br /> j Numher. <br /> 1 I I DdptSize_ --- -- 9 <br /> SEEPAGE PITS — ,, ,1 / Property Li <br /> SUMPS <br /> LI Distance to nearost:h Well Foundation�L_T— <br /> DISPOSAL PONDS n <br /> ccordance with San Joaqur <br /> I hereby certify that I have prepared this application and&.at the work will be done in ain county ordinances,state laves,a <br /> rules and regulations of the San Joaquin local Health DI "I <br /> work for <br /> c Homeany owner of licensed agent's manse gasatuie certifies the to become subject shad not <br /> lto following: <br /> cromfy tpensathat in ion laowsoof California."Contractor's hiring othis�ub-cio.t actinglsignatu e <br /> employ <br /> certifies the following:"I certih;that in the performance of the work for which this Dermic it issued,I shall empl y parsecs subject to workman's compensa <br /> tion laws of Califc",I <br /> The appiTitle: <br /> lcant st call for el uiru inspections.Complete drawing on reverse side. < <br /> Date: _3_- J-ia i <br /> Y: <br /> i Signed X <br /> iL FOR PARTMENT USE ONLY <br /> Y <br /> Date Area <br /> a: - . <br /> y, Application Accepted by — L A f <br /> are h12 <br /> 'q� Final Inspection by-7% —��1� ate3 <br /> 94 r or Grout Ins;Action by <br /> Additional Comments: — <br /> rf ❑Stk 466"6781 ❑Lodi 369-3621 ❑Manteca 823.7104 ❑Tracy a35_62185 r <br /> d f <br /> . j Applicant-Return all copies to:Environmental Health 2ermit/Services 1t01 E.Hazelton Ave.,P.O.Bax 2009,Stk.,CA 95201 <br /> i <br /> CC It RECEIVFo BY DATE I PERMIT No. 1 <br /> y FEE UNT DUE AMOUNT REMITTED LASH <br /> Wim"'"' 7 �^t_ 0 <br /> .EH 11:.IREV.,,wei Q,n� "Z <br /> EH 14-la <br /> .p <br />