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T <br /> APPLICATION FOR PERMIT <br /> RECEIVEDSAN JOAQUIN LOCAL HEALTH DI-STRICT I� <br /> 1601 E. NAZELTON AVE., STOCKTON, CA JUN 2 2 1990 �! <br /> Telephone (209) 466-6781 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> I {Complete in Triplicate} <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 <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. Ii <br /> y IE <br /> Job Address,, l City Lot Size PM I <br /> Owner's Name fel]�GV%� Address � '��=�- Phone II <br /> ContfactoC i Zt Address 'tt� icc i t <br /> i c e n s e No Phone <br /> TYPE OF WELL/PUMP: NEW WELL 'D �".. WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION U( 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 II <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> [Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> F1 Public ❑ Other } 171 Delta Depth of Grout Seal Type of Grout �I <br /> I I Irriflation ---Approx.'.Depth I ) Eastern Surface Seal Installed by I� <br /> Repair Work Done r� <br /> p 7`'_ Type of Pump H.P. '�- State Work Done >�f� <br /> Well Destruction E) Well Diametert Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is I` <br /> available within 200 feet.) I <br /> Installafiori will serve: Residence Commercial_ Other j <br /> I. AI <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:I Water table depth <br /> II SEPTIC TANK Ll Type/Mfg1 Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ i Method of Disposal I� <br /> Distance to nearest: Well Foundation Property Line a <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> wY FILTER'BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth I Size Number <br /> I <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> .DISPOSAL PONDS—­U—­-4_ ..... "r r i. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance Witfi.San Joaquin county ordinances, state laws, aitd <br /> rules and regulations of the San Joaquin Local Health Diktrict. i a <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."Contractor's hiring or sub-contracting signature <br /> permit is issued, I shall employ certifies the following: "I certify that in the performance of the work for which this <br /> p p y persons subject to workman's compensa- <br /> tion laws of California." 1 I� <br /> tiI <br /> The applicant must call r all require i spe#tions. Complete drawing on reverse side. i! <br /> a i <br /> 4Signed X wt's, Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> r� I <br /> Application Accepted by Date � �® Area <br /> Pit or Grout Inspection by } ate Final Inspection by bate 7/1;?A1` <br /> Additional Comments: 1 I! <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK si <br /> FEE �-I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N <br /> +.EH1 -241REV.1/N5} <br /> EH 144.28 <br /> .I <br />