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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I ' 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 2 4 189 <br /> (Complete in Triplicate) <br /> ENVQcation is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo pp f��Other <br /> made in compliance with San Joaquin.County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules?arid� egru� i SanlJoaquin <br /> Local Health District. r <br /> I II`�6�� <br /> Jab Address �M' Cit ._,d-Aces ' PM <br /> Y Lot Size <br /> Owner's Name _�� l�2Uj Address .S Phone <br /> Contractor 6,-ss Mv S, KIL90-Vicense No. Phone - <br /> TYPE OF WELL/PUMP: KNEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> QISTANCE,.TO NEAREST:ySEPTIC,TANK_.- �� - PROP. LINE � r <br /> ®t/ SEWER LINESL =- ` DISPOSAL FLDI2P <br /> FDUNDATION AGRICULTURE WELL — OTHER WELL-Q41,6;!7-PITS/SUMPS <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '7-/`C��Ca <br /> ❑ Industrial ❑ Oen Bottom W— ` <br /> P i �C(Ylanteca Dia. of Well Excavation Dia. o <br /> XDomestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications }} <br /> F] Public ❑ Other ❑ Delta Depth of Grout Seal 4W T 1 <br /> ype of Grout _ <br /> I I irrigation f _Apprd Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> all) <br /> Well Destruction 1 Well Diameter Sealing Material flop 50') i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION LI DESTRUCTION f I (No septic system permitted it public sewer is <br /> available within 200 feet.) ( a <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms = '�^� _ `�� -- - t• i <br /> yl <br /> Character of soil to a depth of 3 feet: n <br /> i Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments = <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distancei�',to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distancito nearest: Well Foundation ,Property Line k <br /> ; f4 <br /> SEEPAGE PITS I I Depth Size Number <br /> _,. <br /> SUMPS ..-.. a,.L-1„!Distance hto- nearest:-��Well=-- - �--Foundation-- propQrty Lihe "" � '" <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and,_ <br /> rules and regulations of the San Joaquin Local Health Di§trict. !! <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 Contractors 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." AA <br /> I <br /> The applicant t ca o all reclyiirfid inspections. Complete drawing on rev se side. <br /> ,M <br /> Signed X Title: Date: +' <br /> I F DEPARTMENT US LY <br /> Application Accepted by a� / <br /> Area <br /> —� <br /> u <br /> Pi or Grout In pection by e Final Inspection by Date <br /> k r a <br /> Additional Comments: <br /> ❑ tk466Ret81 all co❑iesLodi <br /> G9roGn21 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant - Re41(�Return <br /> a is op pito: ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 <br /> I� f-�L AF74 e Era W&& kos 4",J Fr-4&_10 *rJ,0FEE is „� S uzcs <br /> INFO AMOUNT DUE I� AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> CASH r <br /> +.EH 13-24IREV.fiK51 <br /> EH 34-2a <br />