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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTL <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 NOV 8 3989 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERT,IT/5ERMES <br /> i <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 application is j <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 /> Job Addressf+7 �i64 ��1.� City Lot Size PM 1 <br /> Owner's Name Q Address phone <br /> C 1 f�j q! A <br /> Contractor Address ar L'`�icense No. v Phon t <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR f OTHER ❑ <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 Q J <br /> ❑ Industrial ❑ Open Bottom ff Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications <br /> F- ublic f-] Other ❑ Delta Depth of Grout Seal Type of Grout _. <br /> I I Irrigation ­Approx. Dept i I Eastern r Surface Seal Installed by <br /> Repair Work Done 61 Type of Pump' `H.P. 7 State Work Done '? <br /> Well Destruction ❑ Well Diameter - Sealing Material flop 501 <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (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: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 7 _ } Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. &*L,ength of lines Total length/size <br /> FILTER BED ❑ Distance'to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size'""" –_ = ---.__. -Number <br /> ' _. <br /> SUMPS Cl Distance to nearest: _Wel! Foundation Property Liinne=— <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 l <br /> employ any person in such manner as to become subiect to workman's compensation laws of California." Contractor's 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 r all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date4 Area <br /> I <br /> Pit or Grout Inspection by Date - Final Inspection by.:� Date <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT NO. <br /> ♦.EH13-24(REV.1/H5) 35 ,4 C. - j4� <br /> ���0 <br /> EH 14-26 <br />