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APPLICATION FOR PERMIT <br /> „q SAN JOAQUIN LOCAL HEALTH DISTRICT YN1E�T <br /> 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED <br /> Telephone (209) 466-6781 ,U� 1988 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ,,DD^^ ENTp,�HEATH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work VtNM�ri ��p�bation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and R �f"the San Joaquin <br /> Local Health District. <br /> Job Address 177 66' rr. (i) City���Z-M�" Lot Size PM <br /> Owner's Name '1 Address����� `�" �1 Phone - <br /> Contractor +� ��'�G''� Address/n1 V}��'�+k License No./7'� 7- Z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IX <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 ElManteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done t Type of Pump­,.dalv H.P. State Work Done.Qt-k0(1— <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 ` <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. ❑ 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 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."Contractors 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 f I required inspections. Complete drawing on reverse side. <br /> Signed X,� -�'�c-" Title: Date: <br /> FOR D PARTMENT USE ONLY <br /> Application Accepted by a Date /r ,7 Area <br /> insi <br /> Pit or Grout Inspection by Date Final Inspection by DateAr <br /> ✓ " <br /> Additional Comments: <br /> ❑ 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, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. <br /> INFO /� CASH <br /> + EH 13-24(REV.1/e 5) '/ 6� �f U ��0� ;,757,70 <br /> EH 14-26 ✓✓ li lllrrr"' <br />