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40 APPLICA IUN r-UH1 i�tHMII PAYMENT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED <br />1601 E. HAZE`TON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 J U L 5 1984 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate)IKONM'(E/NFTpA`/L�-HHEcALTH <br />RM <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereinn de��t'�i� 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 />.. Address / 1-,�wqtiin Stsre74city C,46� Lot Size o " <br />Owner's Name (1111C U Address 7 ViA, i AA Lt ?A V4,4x UM <br />Phoi <br />.. <br />r ,ttlllurn Wit -1- y a �+ <br />. <br />TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION ❑ d <br />J <br />PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 9, SO bCffln <br />DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLO. PROP. LINE <br />FOUNDATION !CULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial O Open Bottom O Manteca Dia. of Well Excavation <br />❑ Domestic/ Private O Gravel Pack O Tracy Type of Casing (hone <br />(-1 Public .Spec Sd"-n Other ❑ Delta Depth of Grout Seal 10119 <br />I I Irrigation )—.Approx. Depth I I Eastern Surface Seal Installed by <br />Repair Work Done O Type of Pump H.P. Mate Work Done _ <br />Well Destruction O Well Diameter Sealing Material (top 501 <br />Depth 14`DIOX Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I <br />Installation will serve: Residence _ Commercial _ <br />Number of living units: Number of bedrooms _ <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK O Type/Mfg <br />PKG. TREATMENT PLT. ❑ <br />Dia. of Well Casing OWEt _ k <br />Specifications' V� <br />Type of Grout Q <br />AK <br />I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Water table depth- <br />Capacity— <br />epth_Capacity No. Compartments <br />Distance to nearest: Well Foundation <br />Method of Disposal <br />Property Line <br />LEACHING LINE ❑ No. & Length of lines Total length/size <br />FILTER BED ❑ Distance to nearest: Well Foundation Properly Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS 1.1 Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS ❑ <br />I hereby certify that 1 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 District. <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, ! 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: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applica ust all for all re uir inspections. Complete drawing on reverse side. <br />Signed X Title: 061PUIA Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by Date e`Z _06 Area <br />Pit or Grout Inspection by Date Final Inspection by Date <br />Additional Comments: <br />O Stk 466-6781 ❑ Lodi 369-3621 O Manteca M7104 O 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 />e.EH 13.241REV. 1/x5 <br />EH 14.26 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT'NO. <br />a <br />