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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED JUL 13 1988 <br /> (Complete in Triplicate) .ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work hereipph��i�� tt ica ion is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weVpump and the Rules and F egu a -o ''pp Joaquin <br /> Locat Health District. �} <br /> Job Address E - City Lot Size PM <br /> Owner's Name �_ Address l�5 dA. <br /> J Phone 272_—`68L <br /> Contractor Al 0 eAddll-46 Address//'/—/'27-- `� License No.�f�s;�2rze1 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑, <br /> PUMP INSTALLATION ❑ I SYSTEM REPAIR ❑ OTHER l <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS - <br /> INTENDED USE 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 i <br /> M Public ❑ Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done I� Type of Pump,.4"I," H.P.1_ =- State,Work Done t�Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 J_;�-1 <br /> Depth Filler Material {Below 501 ° 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f'I REPAIR/ADDITION I.I DESTRUCTION l 1 INo septic system permitted it public sewer is <br /> available within 200 feet.] <br /> I <br /> Installation will serve: Residence_ Commercial____ Other <br /> Number of living units: Number of bedrooms �--� <br /> Character of-'soil to a depth of 3 feet: a Water table depth \` <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation F Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size s Number („_ <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> -...DISPOSAL-PONDS- _ ❑ - <br /> 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 become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 must call r all required inspections. Complete drawing on rave a side. <br /> Signed X Title: Date: d'r7 <br /> FOR DEP TMENT USE ONLY �— t <br /> 5 <br /> Application Accepted byDate Area i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> S <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 835-6385 t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> CK <br /> INFO AMOUNT DUE AMOUNT RENIITTEt),::, ''ASH`�/ RECEIVED BY DATE PERMITNO. <br /> +.EH 13-24{rtEV. U �-►t <br /> EH 14-26 V V ��,C/JC3 [J /I• I ��j <br />