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APPLICATION FOR PERMIT <br /> ;.z <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 FEB 1 6 9989 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUE(] <br /> ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES <br /> I plication is <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 ap <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 /> r Lot Size PM <br /> Cit►La y <br /> Job Address i i I' r <br /> z Phone <br /> Owner's Name "" 1t1`�'�' - ddre <br /> I <3 #4 Phone <br /> Contractor <br /> Address ___ �� � � License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑` _DESTRUCTION ❑ <br /> r PUMP WSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> IDISPOSAL FLO. PROP. LINE <br /> 1' DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES <br /> 1 FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> industrial ❑ Open Bottom 1-1MantecaDia. of Well Excavation Specifications <br /> i [Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> r'1 l-1 Delta Depth of Grout Seal Type of Grout <br /> Other r <br /> F1 Public [ - <br /> l I I Irrigation —.-Approx. Depth l I Eastern n Surface Seal Installed by <br /> Type of Pum H.P. State Work Done <br /> Repair Work Done � Vp ; P <br /> Well Destruction L] Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'} <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION i I DESTRUCTION I I a o z;eptic system <br /> hin m perm(emitted if public sewer is <br /> Installation will serve: Residence Commercial­ Other <br /> r <br /> Number of living units: Number of bedrooms <br /> I <br /> Water table depth <br /> Character of soil to a depth of 3 feet: t <br /> Capacity No. Compartments <br /> SEPTIC TANK -111 �'TypeiAfg Method of Disposal , t <br /> PKG. TREATMENT PLT. ❑ <br /> k Property Line <br /> Distance to nearest: Well . _ Foundation <br /> X", Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> nEe to neatest: w11 ell <br /> plumber <br /> Foundation. Property Line <br /> FILTER BED ❑ "DistaF + <br /> SEEPAGE PITS t I Depth f Size <br /> SUMPS Cl. Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Y ❑ <br /> I hereby certify that 1 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 Di§trict. <br /> ertify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I c <br /> compensation laws of California." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's <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 applican all for all requ'ed inspections. Complete drawing o verse side. 1j <br /> Till Date: <br /> Signed e: <br /> .77-7 2— <br /> t <br /> F EPARTMENT USE ONLY <br /> /13 <br /> k Date Area <br /> Application Accepted by �g <br /> Data Final Inspection by <br /> Pit or Grout Inspection by kms' Date� - <br /> Additional Comments: R <br /> ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200A, Stk., CA 85201 <br /> FEE Jr CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +.EH 13-24 tREV.r i n 51 <br /> EH 14-25 <br />