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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE,, STOCKTON, CA PAYMENT <br /> Telephone (209) 466-6781 RECEIVED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) MAR 12 1990 <br /> SAN JOAQUIN COUNTY <br />! Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hKAWCac L ��s� "I'l <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rul <br /> Local Health District. r �1 t� r W�lm, <br /> Job Address 0C +-�iN <br /> Q City J 1 1 Lot Size_ �Och <br /> • PM <br /> Owner's Namer pr'E 44dress <br /> ff Phone <br /> Contractor 16A i16gddressGtl+tn�rt�.�� 4}', Gros) �b�✓ <br /> s4�TG d� License No. <br /> TYPE OF WELL/PUMP: Phone_ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWER LINES DISPOSAL FLD. PROP. LINE -llr <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I IndustrialPrOill 05 <br /> ❑ Open Bottom �I Manteca Dia. of Wall Excavation r� �K��r <br /> !❑ DomesticlPrivate Dia. of Well Casing <br /> ❑ Gravel Pack ❑ Tracy Type of Casin - . 4d $� Qqt <br /> M Public o Other Specifications <br /> 1 ��� CI Delta Depth of Grout Seal �aQ�� � <br /> I i Irrigation A Type of Grout »� <br /> pprox. Depth I"I Eastern Surface Seal Installed by w��! <br /> Repair Work Done ❑ Type of PumpH.P- h \ <br /> Well Destruction Well Diameter '' w State Work Done, <br /> SealinW f <br /> g Material (top 50') (\ { <br /> Depth `r Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Res' encs G available within 200 feet.i <br /> Commercial��pther <br /> Number of living units: —„E— Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK <br /> ❑ Type/Mfg Capacity_ <br /> PKG. TREATMENT PLT. CI ` No. Compartments � <br /> Method of Di osal <br /> Distance to nearest: Wel!�g Foundation _ <br /> ._ Property Line h/ p <br /> LEACHING LINE ❑ No. & Length of lines h`- <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundations <br /> 1 � Property Line_ hl4 <br /> SEEPAGE PITS I 1 Depth Size _ <br /> Number <br /> SUMPS <br /> CI Distance to nearest: Well Foundation.. <br /> DISPOSAL PONDS ❑ Property Line_ <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 FD4st cadl iced " spections. Complete drawing on reverse side. <br /> Signed X ^� <br /> Tide: S Date: <br /> FO EPAR T USE ONLY <br /> Application Accepted by / <br /> Date <br /> Pit or Grout inspection by Data <br /> Final Inspection b Date��67 <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, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED By DATE <br /> PERMIT'NO. <br /> +.EH 13.24 IREV.i/n sr <br /> EH 14-28 <br /> a O S� <br /> 1' <br />