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law <br /> APPLICATION FOR PERMIT *age C E I V E DK <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT NOV 2 7 1989 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ENVIRONMENTAL NFAL TH <br /> Telephone (209) 466-6781 PERM I T/ R1;IC, S <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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. <br /> Job Address _190-7 City Lot Size I Z x PM <br /> Owner's Name t� `fit`i f— Address 7-2 E C4,9,e SN-PIL6r- Phone 477- 6246 <br /> ContractorOt r'-cwai Address 2�t�i�W z� Llcense No.�6��" Phone d- �7L <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 .,.�1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES rLO DISPOSAL FLD. PROP. LINE fu <br /> FOUNDATION AGRICULTURE=WELL OTHER WELL — PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Iv] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> [-I Pubtic E] Other n Delta Depth of Grout SealIM4,4--OF Type of Grout__ <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by d"X 3-0 u141C C .,A,r7 fr41✓4 fwC�1Y <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Weft Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L] Distance to nearest: Well Foundation Property Line <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 Dihtrict. <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 /> certifies the following: "1 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 for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: dwLl Date: <br /> _ TMENT USE ONLY <br /> Application Accepted by Date/ ' Area <br /> Pit or Grout Ins ;Z-h� S <br /> Inspection by � h�-�iC Date Final Inspection by �1 `vI�[�"-`�[ , ---- Date �Z <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 96201 <br /> lFliF Q AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-74 ra£y,I <br />