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APPLICATION FOR PERMIT <br /> SAN• JOA��QUIN LOCAL HEALTH DISTRICT �I� 1601 Ell`Id. ?ZEI'T0NNNVE„ STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) SL P `' 1988 <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 amLRBeHIFtigP. 4yi1��a�1{ �{'� <br /> Local Health District 1 r EWAT/SERVICES, <br /> 4l/� W iy SLA Ciry�9bM,6 a PM <br /> Job Address Met - t t I I ,Q r <br /> yYtet V' r rA it _ Address 40Q/'1 W fd�i/.111✓C>Z f lt7 . 4 hone <br /> Owner's Name r \, <br /> Contractor } Address )0 QD'JC(Qji 1 License No.tklPhone <br /> TYPE OF WELLPUMP: dg N W WELL ❑_ / WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> IP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ J it <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Iryj <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSJSUMPS �- <br /> INT NDED SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� I <br /> ndustriai {'L ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4{ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specil.....ns t f <br /> 4 Type of Grout— —. <br /> FI Public ❑ Other <br /> 171 Delta Depth of Grout Seat t <br /> 1 1 Irrigation _LApprox. Depth I I Eastern Surface 1 Installed by <br /> Repair Work Done ❑ Type� of Pump a �b H.P. 17 Stats Work Dane /F'✓v'� <br /> c/t,j <br /> Well Destruction ❑ We11 Diameter Sealing Material (top 501 .fj• t <br /> .Depth Filler Material tBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> • available within 200 feet.l p <br /> Installation will serve: Rest3dence—. Commercial_ Other <br /> Number of living units: I Number of bedrooms S <br /> Character of soil to a depth pf 3 feet: Water table depth <br /> 1 , Ca cit No. pts I <br /> SEPTIC TANK �. ,dyVPe/rMfg,+, 1, Capacity— Compartments <br /> I <br /> rKG. TREATMEN3p„LTh ­ Method•of_Disposal <br /> 56—�_ istance to nearest: Well! ' Foundation Property Line upup <br /> LEACHING LINE ❑ No. &Length of lines � � ��VI Total length/size t �� <br /> -� <br /> ' FILTER BED Cl '�ggDistarue to nearest: Well Faund'ation Property Line yyf <br /> SEEPAGE PITS I l epth Size Number i I: <br /> SUMPS ❑ istance to nearest. Well _ Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I r <br /> I hereby unity that I have prepared this application and that the work will be done in acwrdance with San Joaquin county ordinances, slate laws4 and <br /> rules and regulations of the San Joaquin Lout Health D3trict. <br /> Ham owner or I' is signature certifies the following: "i certify that in the pertormance of the work for which this permit is issued,I shall not <br /> r employ any n in such or as to become sublect to en's co nsation taws of California."Contractors hiring or sub-contractirq signature <br /> certifies the aAowtng:"i certify at i the 1,rfor ce of w for h this r it is issued,I shat)employ persons subject to workman's compensa- <br /> tion laws California." r <br /> The appli nt must It for . ired Ins cC pre n on 4 �, <br /> Date: <br /> Signed � ' <br /> FOTD <br /> RTMENT USE ONLY <br /> r ` Date Area <br /> Application Accepted by / �I <br /> Date Fnal Inspection by Date <br /> Pit or Grout Inspection by SII <br /> I r <br /> Additional Comments: . <br /> ❑ Stk 466-6781 ❑Lodi 369-3621 13 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 95201 <br /> i�• <br /> i <br /> FEE AM6UNT DUE AMOUFIT REMITTED CASH RECEIVED BY DATE PERM,T'NO. <br /> INFO <br /> eH,aze <br /> A I <br />