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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZELkON AVE., STOCKTON, CA RECEIVED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jft J 1987 <br /> (Complete in Triplicate) <br /> NVWQM"SLj�jJIUSDfSTN <br /> Application is hel,eby made to the San Joaquin Local Health District for a permit to construct and/or insta 1 es application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rp[* the San Joaquin <br /> Local Health District.. 1, n f/. ] I f <br /> Job Address <br /> `7 �f rV�t F'''7 �5Y7:'in �P,Ciiy ACI-e—t�G.�L-►Lot Size e���t (_� r PM <br /> 11// �jF �f t .C/LI ®Gv Address JfPT � Phan <br /> Owner's Name <br /> Contraclo ✓IL 49�G� nJ L1 air' Address t Oo 14 O-D CoNC"X' e•t License Ivo3 10 Phone 6�� �' � <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ + <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES i ISPOSAI_ FLD. POOP. LINE ^� <br /> FOUNDATION AGRICULTURE WELL fon ITHER WELLZ 60 0 PITS/SUMPS \. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS If <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation d Dia. of Well Casing <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing 4 Specifications t A <br /> F1 Public. f D her ; f-! Delta Depth of Grout Seal 10 Type of Grout <br /> I ! frnyation # �20 APProx. Depth l 1 Eastern Surface Seal Installed by�V f u? �7' ��L <br /> Repair Work Done ❑ Type of Pump <br /> WP, State Work Done _ r <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ,r 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 /> 1 <br /> SEPTIC TANK ` ❑ Type/Mfg Capac' No. Compartments <br /> PKG.-TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well .-Foundation Property Line <br /> t <br /> LEACHING LINE ❑ No. &;et;o <br /> 'nes Total.length/size <br /> a <br /> FILTER BED ❑ Dis nearest: Well Foundation Property.Line j <br /> SEEPAGE PITS [l Depth Size Number <br /> SUMPS I L� Distance to nearest: Well Foundation Property Line <br /> DI OSAUPONDS #_ ❑ <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 /> i <br /> The applicant m ca or ai ra uired inspectio Complete drawing on brse side. <br /> i Signed X Title: <br /> r 'r` Date: <br /> R P M SE ONLY <br /> Application Accepted y Date ��a Area <br /> Pit or Gfout Ins ' io Date Final Inspection by Date _ <br /> t <br />€ Additional Comments: <br /> E <br /> El Stk 466.6781 ❑ Lo 369-"3 ADManteca 823-7104 ❑ Tracy' 835 <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 H RECEIVED BY DATE PERM17-'NO. <br /> INFO y <br /> ♦ EH 13-24(REV.t/ <br /> IN x'71 �i•.�� - - <br />