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APPLICATION FOR PERMIT 'PAYMENT <br /> SAN JOAQVIN LOCAL HEALTH DISTRICT RECEIVED <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> • Telephone (209) 466-6781 NOV 17 1988 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplieatel ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for aPERMITI.SERVICES <br /> permit to construct and/or install the work herein des ribed.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 o^ 7 T Y-)N�. . N R '}- C <br /> ( City 4�'AI 1 (d size 66 A PM <br /> Owner's Nam, A E b e e y,, b-ac Y1 �,Xddress S -a1�'@. Phone 9 3 , <br /> ContralWV c,tn c� S Address i.`i.YAr8 SToC F(af�l t3Lfaense No/ j G 3Phone-'gS—/d <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR a-- OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 -/bb SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> fd-0omestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications <br /> fl Public n other n Delta Depth of Grout Seal Type of Grout— <br /> ­ <br /> I I Irrigation ­Approx. Depth t I Eastern Surface Seal Installed by _ <br /> Repair Work Done 0" Type of Pump H.P. State W�oprk�Done T r <br /> Well Destruction ❑ Well Diameter ')t3� VlSA.1L <br /> Depth FASI`A lew.601I S' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION t 1 DESTRUCTION 1 1 (No septic system permitted if public sower 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 ❑ 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 Ll Distance to nearesr. Well1 <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ - t <br /> 1 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 Di3trict. <br /> Home owner or licensed agent's signature cenifies the following; "I certify that in the performance of the work for which this permit is issued, I shag 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 fONOMng:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's cortlpensa- <br /> tion laws of California." <br /> The applicant <br /> tmmust <br /> jcall for al required inspections. Complete drawing on reverse side. <br /> Signed X- Title: Date:l'L <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by Date a' � Area [ r <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 8364385 <br /> Applicant- Return all copies to; Environmental Health Permit/Servims 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> • FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO ��6��' ICAASSH� DATE PEERRMIT'NO. <br /> •.ER 1Y7z IREV.rrxal ��4� 43V <br /> EN 1470 l/w.J 1 <br />