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4 <br /> F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZET ON AVE., STOCKTON, CA <br /> F. Telephone (209) 466-6781 I <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED i <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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> f , <br /> Job Address 5170 N. Flood Rd. k City Linden Lot Size _ PM <br /> i <br /> Owner's Name M & R. CO/M. B0 ian0Address 15219 E. Eight Mi1t=_ Rd. Phone <br /> h t <br /> ContractopRryiELncp Drillers �. �'.O.BO� 64�Llnden License NoA- 9.23 Phone ,yy <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ T <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 /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS #' <br /> ❑ Industrial )U Open Bottom ❑ Manteca,, Dia. of Well Excavation _ Dia. of Well Casing 160D <br /> 1 <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Steel Specifications •�-$$ i <br /> 1'1 Public nOther C-1Deltaepth of Grout Seal Type of Grout <br /> Xi Irrigation ­Approx. Depth f I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. %-1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') r <br /> Depth Filler Material (Below 50') `vim <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l`} DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other J( f <br /> Number of living units: Number of bedrooms jv <br /> Character of soil to a depth of 3'feet: ' Water-table depth <br /> SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 9 Method of Disposal , <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 i° »Foundation �-- - Property"=Line-- <br /> SEEPAGE PITS I I Depth Size Number <br /> a <br /> SUMPS L1 Distance to nearest: Well. Foundafion PropeFty 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 Diktrict. 4f <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 <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 ora r d inspections. Complete drawing on reverse side. r <br /> . <br /> Signed X Title: P3resident'� Date: 2/8/89 <br /> FOR DEPARTMENT USE ONLY <br /> 11— �J <br /> Application Accepted by — /' 1 r Date k Area l <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMI7'NO. <br /> INFO CASH <br /> +.EH1 -24(RE <br /> EH 14-28 <br /> v.fin5] <br />