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I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA &� <br /> Telephone (209) 466-6781 sA c ' <br /> el " <br /> c. <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED S�> r 8 1992 <br /> _ (Complete in Triplicate) �� �/yy�pfLIC H � Cc�UI����}, <br /> i, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worn lit tlf$ c i S htsragp)ication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weVpump and the Rules and Regaa`ti8n�s of FFA San Joaquin <br /> Local Health.District�­ ­�-} r F" O S 2� <br /> Job Acldressdfi `� - of Size PM <br /> Owner's Name ��1� /,,�-fnr �'C U6 Ar Aress I[l� 1 ^1 , Phone 34,9 29 Y ~ <br /> Contfactor 7 --CAddress l All 5! C ST Licens�No. TLYVPhorie <br /> TYPE OF WELL UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k PUMP INSTALLATION ❑-- SYSTEM REPAIR CK OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> — INTENDED USE TYPE OF WELL PROBLEM AREA YCONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation A: Dia. of Well Casing <br /> t D Domestic/Private ❑ Gravel Pack D Tracy Type of Casing. Specifications ) <br />' i'].Public Cl Other D Delta Depth of Grout Seal Type of•Grout <br /> f Irrigation _"Approx..Depth I I Eastern Surface Seal Installed by �. <br /> II Repair Work Done ❑ Type of Pump / H.P. I� State Work Done �' 15,9 W <br /> . Well Destruction ❑ Well Diameter Sealing Material atop 50') I ' <br /> iDepth I Filler Material (Below 50') �, n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 'REPAIR/ADDITION l I DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will serve:3 Residence Commercial_ Other w E <br /> Number of living units: Number of bedrooms <br /> I Character of soil to a depth of 3 feet: -tf Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity t,.No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />{ l ` <br /> SEEPAGE PITS I I Depth Size Number <br /> _ SUMPS _ _ 0 Distance to nearest: Well Foundation - r Property Line <br /> I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> E 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 /> f certifies the following: "I certify that in the performance of the work for which this permit is issued,I shaff employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must ca for all required inspections. Complete drawing on reverse side. 1 9 <br /> Signed X Title: Date: _C C� <br /> FOR DEPARTMENT USE 9LY <br /> Application Accepted by CO-1.�� Date Area Z <br /> Pit or Grout Inspection by t :Date Final Inspection by atei 1��� R <br /> Additional Comments: r' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> INFO AMOUNT DSUE AMMOOU[N�T REMITTED CK CASH RECEIVE) BY DATE PERMIT NO. <br /> +.EH 13-24(REV,1/9 sl v LJ,�`� ✓ 'o a <br /> EH 14-28 <br />