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• � LLQ_ <br /> E -Al <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 PAYMENT <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVED <br /> - (Complete in Triplicate) T ''00 p <br /> i Q912 r el$kl <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workQ91 s nb 1s application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rr n � res® yan Joaquin <br /> Local Health District. " PUBLIC HEALTH SF'P?Ii, G <br /> ENVIRONMENTAL HEAL'tH DIVISION <br /> Job Address _ 16744 S—OT AGF DRIVE City Lot Size PM <br /> Owner's Name Address SAME. Phone - <br /> 5728 <br /> I. n ractor <br /> LARSEN PUMPS, INC•Address LLY 77hfifs0 License Na. Phone — <br /> Co <br /> f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ L►LL to DESTRUCTION LD <br /> PUMP INSTALLATION>( SYSTEM REPAIR ❑ OTHER ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS <br /> INTENDED USES TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout­—­­ <br /> I <br /> rout -._-I E Irrigation Depth l I Eastern Surface Sedl Installed by a - <br /> Repair Work Done ❑ Type of PumpJA�Z:L- H.P. '•SM930 90-SlA�State Work Done Jt <br /> Well Destruction 0 Weil Diameter Sealing Material [top 501 <br /> Depth Filler Material IBelow 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> E Installation will serve: Residence— Commercial— Other ( <br /> Number of living units: Number of bedrooms <br /> k Character of soil to a depth of 3 feet: Water table depth r <br /> €� SEPTIC TANK U . Type/Mfg Capacity No. Compartments ]� <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> f I hereby certify that.l havepreparedthis 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 /> I 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 u call for ail r uire " spections. Complete drawing on reverse side. <br /> Signed X Title: Date: A <br /> i � ,IFQR DEPARTMENT USE ONLY �•a��� 12/� <br /> r Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date e <br /> Additional Comments: <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 51k., CA 955201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO f r p 1_ <br /> +.EH 13-24(REV.1/85) �y' 0 --,>s_C)``l It 607 /0 -3Q"'i "'2(073 <br /> I EH 14.28 <br />