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`-` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ? 5 <br /> 9 <br /> �1 E. HAZE�TON AVE., STOCKTON, CA �"� <br /> Telephone {209} 466-M, J 1,L 5 1988 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �ht�t-mss {Complete in Triplicate} EN11ftrvIENTAL HEALTH <br /> L . <br /> Application is hereby made to the San Joaquin Local Health District fora ���I �� ���CES <br /> made in compliance with San Joaquin County Ordinance Health <br /> 549 for Permit to construct and/or install the work <br /> Local Health District. herein described.This application is <br /> sewage or No. 1862 for waif/pump and the Rules and Regulations of the San Joaquin <br /> Job Address Cl 715-1 c4 <br /> ' .City C Lot Size rv~ <br /> Owner's Name f�Cl / ze PM <br /> Address C -- ace"6 <br /> "rwQ�� <br /> Phone L! OZ <br /> ddres <br /> TYPE OF WELL/PUMA: NEW WELL License No. Z Z Phone <br /> PUMP INSTALLATION ❑ r WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES �� DISPOSAL FLD.L <br /> FOUNDATION ��•.AGRICULTURE WELL � PROP' LINE <br /> INTENDED USE TYPE OF WELL -OTHER_WELL- ._�_PITS/SUMPS. <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS -� <br /> ❑ dustrial ❑ pen Bottom. ~— (l <br /> mestic/Private ❑ Manteca Dia. of Well Excavation <br /> .Gravel Pack � Dia. of Well Casin <br /> ❑ Public . Type of Casin g <br /> ❑ Other l ❑ DeltabSpecifications l (� 1 J <br /> CI Irrigation Depth of Grout Seal <br /> PpuDepth ❑ Easter Surface Seal Installed y R Type of Grout <br /> Repair Work Done IJ Type of pump �ttt <br /> Well Destruction ❑ H'P' State Work Done r <br /> WeN Diameter Sealing Material(top 501) <br /> Depth t l <br /> Filler Material (Below 50) V <br /> TYPE OF SEPTIC WORK: NEW IN ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septi <br /> P system permitted if public sewer is <br /> Installation will serve; Residence Commercial available within 20O feet.) <br /> Number of livingunits: Other <br /> Number of bedrooms ` <br /> Character of soil to a depth of 3 feet: "] <br /> SEPTIC TANK , ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity-- No. Compartments i <br /> + Distance to nearest: Well i Method of Disposal <br /> Foundation.�„� Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: We!! Total length/size (� <br /> i Foundation Property Line 4 <br /> SEEPAGE PITS ❑ Depth ) Size " <br /> ;SUMPS_ 13 Distance to nearest: Well Number <br /> `DISPOSAL PONDS r ❑" �,� - Foundation Property Line <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 th performance of the work for which this <br /> tion laws of Califor ' permit is issued,!shall employ persons subject to workman's Compensa- <br /> The applicant ust call for r inspections. Complete drawingjon ]0;side, <br /> x _ <br /> Signed Iiy n <br /> Title: Date: <br /> „y t F R DEPARTMENT USE ONLY <br /> Application Accepted by �--� _ <br /> ` el 0- <br /> Date ' .L—� Area <br /> Pit or Grout Inspection by Date /� �6 <br /> �- Final Inspeatmon by Date <br /> Additional Comments: f" "' <br /> ❑ 5tk 466-6781 ❑ Lodi 369-3821 ❑ Mante 973-7104 ❑ Tracy 835-63% <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 CK <br /> INFO ^ CASH RECEIVED BY DATE PERMIT"NO. <br />+ EHI24tREV.t/851 <br /> W 6/ ' <br /> EH 1428 - <br />