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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> `SUN 2 4 1986 <br /> Telephone (209)'466-6781 ENVIROMEN fAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FERMIT/SERVICES r <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. �r <br /> Job Address �p1,140 41'r L 62, City Trig• Lot Size PM <br /> l 1 d• 7-:50A Phone <br /> Owner's Name /mss) Address <br /> } ,yam -T���� RIO <br /> Contractor /�/Y 5 K&JZWddress R License No. ���G_Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION* k SYSTEM REPAIR--F] �a - OTHER-9--------'*� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br />-� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETYPE-OF-VVEL�'PROErLEM:kRgk-�--MSTRUCT40N- EC:4FI6 TIONS ie' <br /> ❑ Industrial ❑ Open Bottom ❑,Manteca Dia-of Well Excavation. /0 Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy r Type of_C_asin ..-,.FS r�I! Specifications Z <br /> ❑ Public ❑ Other_ .-._ ❑ -Delta. - Depth of Grout Seal 3'Q �'f Type of Grout OG� r <br /> ❑ Irrigation .-Approx. Depth ❑ Eastern a Surface Seal Installed by ��/�f� <br /> Repair Work Done ❑ Type of Pump 51714 H,P..I 02 State Work Done <br /> Well Destruction ❑ Well_Dialmeter Seal!II g y w <br /> o d Material' 50'1 <br /> Depth I Filler Mat 'I <br /> (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mb..septic system permitted if public sewer is <br /> available within 200 feei.)' <br /> Installation will serve: Residence— Commercial_ Other <br /> i <br /> Number of living units: `:1� Numbbr�of bedrooms 1 <br /> Character of soil to a depth of 3 feet �'%ater table depth <br /> SEPTIC TANK ❑ Type/Mfg I CapacIN- '�-No. Cori partments 11 <br /> PKG. TREATMENT PLT. ❑,, Method of Disposal <br /> ista <br /> Dce to nearest: Well i Foundation_.A, Property Line <br /> 1 � ._._......�.,_-i� � <br /> ' I f <br /> LEACHING LINE ❑ No. & Length of lines ; t � �_ Total lengthlsizek <br /> .. t <br /> FILTER BED El} Distance to nearest: Well { Ioundation Property Line` <br /> SEEPAGE PITS ❑3 Depth Size -` E P - Number <br /> SUMPS ❑, Distance to nedrest: ell Foundate P o'e`rtyLine { <br /> DISPOSAL PONDS ❑ _ r ~ � <br /> I hereby certify that I have prepared this application and that the work will be done in ordance with•Sva1 Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Lo&ArNeal#h Distric6 V•,1 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this-per.Tnit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation lays-&California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit isissued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantst call for required inspections. Complete drawing on reverse ide. <br /> l <br /> Signed X /! Title: ��!/ .S C - Date: 4 <br /> FOR DEPARTMENT USE ONLY <br /> /M �7 �' /1 <br /> {�4pplication Accepted by V ` Date�" � —p-� Area <br /> Pit or Ospection by Date 7-1-540 Final Inspection by 46T7W,14 VDate OLIV' , <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 95201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH13-24SREV.�/A5) <br /> EH 1428 <br />