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APPLICATION FOR PERMIT ( <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT <br /> Telephone (209) 466-6781 RECEIVED <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (C )mplete in Triplicate) 'MAY 2 9 1989 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install UIV� P%PAWNf4s application is <br /> SWWmade in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well!pump apd„h €NTAL EAI L}4V$ION San Joaquin <br /> CCIlYO k <br /> Local Health District. <br /> Job Address —9y-2—G� � City A- Lot Size PM <br /> ' <br /> CIA <br /> Phone r <br /> Owner's Name Address <br /> 77 <br /> Address ALT ansa No. one <br /> Contractor <br /> TYPE OF WELL/PUMP: ]i NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> fJlO'Z <br /> PUMP INSTALLATION Ll SYSTEM REPAIR LJ OTHER <br /> ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P815P. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT515UMP9 <br /> iF <br /> INTENDED USE n TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ ,Open Bottom E5 Manteca Dia. of Well Excavation ia. of Well Casing <br /> I _❑ Domestic/Privy ///---11 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> hl <br /> 1-1Public <br /> F, `O` ther F.1 Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation A�b_Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> H-p, State Work Done <br /> Repair Work one ❑ Type of Pump <br /> Well Destruction ElWell Diameter Sealing Material Itop 501 [� <br /> Depth Filler Material (Below 50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION l I DESTRUCTION I 1 INo 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 A' <br /> f Character of soil to a depth/of.3 feet: Water table depth <br /> { SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PET. ❑ <br /> ' Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line Q <br /> SEEPAGE PITS I'I Depth Size Number jp✓�' <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ Citi' <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 Diltrict. <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 manb <br /> manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> f 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." 0 <br /> r The applicant must call for all re wired in Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> Ii <br /> I� FOR DEPARTMENT USE ONLY <br /> Application Accepted by em r4 <br /> Date Area <br /> el <br /> Pit or Grout Inspection byD,aOto Final Inspection by Date 9D <br /> Additional Comments: r'k Arw <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 0' e�6, 41J10 <br /> i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> qN� <br /> i <br /> FEE <br /> M <br /> AOUNT DUE AMOUNT REMITTED K RECEIVED BY <br /> INFO <br /> DATE PERMIT'NO. <br /> r�. r <br /> +.EH t3-24 iREV,kirisk 7 I �f � a ��—i� p <br /> EH 1428 <br />