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PAYMENT <br /> RECEIVED <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL:HEALTH DISTRICT SEP 1a 1988 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES VYEAR FROM DATE ISSUED PEIT�SERVIC $ <br /> {Complete in Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address - Citym Lot Size PM <br /> Owner's Name Address IL IL h � i Phone <br /> Contractor ' AddressZZZ27Y License No.Zl" � Phone <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <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 /> i <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications w <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t Type of Grout <br /> ❑ Irrigation <br /> --Approx. Depth ❑ Eastern Surface Seal Installed by E <br /> . "V <br /> Repair Work Dane O Type of Pump H.P. State Work Donee \ry <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') `V <br /> Depth "" Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION D REPAIR/ADDITION ❑ DESTR CTION Of(No septic system permitted if public sewer is <br /> -o- t �'t ' t• 1 available within 200 feet.) <br /> Installation will serve:. Residence_ Commercial— Other'. . - . <br /> q� <br /> Number of living units; Number of bedrooms s <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No: Compartments <br /> d <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> Distance to nearest: Well Foundation 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 ❑ Depth Size 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 sub-contracting signature f <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 applicantJmgst c II far II required inspections. Complete drawing o everse side. /'/� /y <br /> Signed X " Title: � 1�, ..— Date: 11 tZ/d"ri' _ <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by Date l Area <br /> Pit or Grout Inspection by Date Final Inspection by 2Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV.1/85) LA ep <br /> EH 14-26 (f!/ CCC/// <br />