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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (2)9) 466-6781 AUG 31 1987 . ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in,Triplicate} ,, IENVIROMENTAL HEALTH <br /> il::' ;: '...,• ... ; r{.. • FFRMIT/SERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escribed. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1562 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 7, 5 <br /> Job Address 32,) ,l�y 1i +"�a� City Lot Size PM <br /> Owner's NameAddress ' ` Phone ' <br /> _a <br /> Contracts Address pd i �4 �n "ten ase License No r����-_Phone l <br /> TYPE OF WELL/PUMP: :;NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` DISPOSAL FLD. PROP. LINE <br />'i FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE •TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS"" <br /> ❑nIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other j ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx..Depth ❑ Eastern y-Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump —dct H.P. State Work Done tiri a <br /> Well Destruction © Well Diameter Sealing Material (top 501 <br /> Depth` Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is { <br /> available within 200 feet.) <br />` Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms _k - <br /> Character of soil to a depth of 3 feet: - * ' -`Water table depth _ Qi <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. CI F ' Method of Disposal <br /> - 0. r <br /> Distance to nearest: Well Foundation Property Line <br /> bS ci 1 ` <br /> LEACHING LINE Ll No & Length of lines f �� Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation\N Property Line <br /> SEEPAGE PITS ❑ DepthSize - Number i <br /> SUMPS ❑ Distance to nearest: Well- - Foundation 'Property Line <br /> DISPOSAL PONDS ❑ i _ I _I r f� . a _...�.��T^ --•r+r <br /> 4�I 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 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 be�c me subject-to,workman's compensation laws of California Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that in the a performance_of the v o-rk'-for which thispermitis issued, I shall employ persons`subject to workman's compensa- <br /> tion laws of California." -�- --- _ -- <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> k r <br /> Signed Title: Date:CJ <br /> i FOR DEPART ME T USE ONLY <br /> Application Accepted by I Date ! <br /> Pit or Grout Inspection by I Date Final Inspection Date 2 C <br /> Additional Comments: ' Y <br /> ❑ Stk 466-6751 ❑ Lodi �369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> i r <br /> FEE <br /> INFO AMOUNT,DUE* AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.1./n 5) <br /> EH 14-28 <br />