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r <br /> APPLICATION FOR PERMIT D CM <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ((( <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone-(209) 46676781 JUN Q 1988 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) EN��)q�NiEN7p "E <br /> TIRration is <br /> Application.is hell made to the San Joaquin Local Health District for a permit to construct and/or install the,Rules and Regulations San Joaquin <br /> work <br /> � 1 � <br /> made in compliance with San Jdaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the <br /> Local Health District. Lot <br /> City t Size' �az'7 <br /> yJ�ob Address ^� �elp <br /> I 171 71-5 �J i � 3 70 <br /> r�l l I t Address •�� /' Phone <br /> Owner's Name �y ?_ <br /> �. / r Phone <br /> Contracto <br /> Address nse:No. <br /> TYPE OF WELL/ UMP: NEW WELL WELL REPLACEMENT Q DESTRUCTION ❑ ; <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ �_ — DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 3AGRlCULT_URE WELL_ _OTHER WELL PITS/SUMPS <br /> --• FOUNDATION -. <br /> a ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIDN SPECIFICTIONS pia. of Well Casing <br /> [I Industrial Fe. Bottom ❑ Manteca Dia. of Well Excavation Specifications 10491! ❑ Tracy Type of Casing <br /> Domestic/Private ❑ Gravel Pack Depth of Grout Seal 150 y Type of Grout—..._.-.$A- ---- <br /> "1 Public n Other } F1 Delta <br /> I I Irrigation , Approx. Depth l I Eastern Surface Seal Installed by <br />'4H P State Work Done <br /> Repair Work Done ElType of Pump <br /> Well Destruction ❑ Well Diameter Sealing Materia! Stop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW WSTALLATION 11 flEPAIfllADDITION l i DESTRUCTION l I (No <br /> 1wthin m permitted if public sewer is <br /> 200 feet.) <br /> 3 Installation will serve: Residence ` Commercial_ Other <br /> i Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK L7 Type/Mfg Capacity <br /> Method of Disposal <br /> PKG, TREATMENT PLT. ❑ .1 Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line ' <br /> FILTER BED (i Distance to nearest: Well Foundation <br /> Number <br /> SEEPAGE PUTS f I depth Size Property Line _ <br /> � SUMPS L1 Distance to nearest: Well Foundation accordance with Sa�Joaquin county ordinances, —� <br /> DISPOSAL PONDS.. ❑��-- --' ��""�r antes, state laws, and <br /> lication and that the work will be done in a <br /> I hereby certify that I have prepared this app . . <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, I shall not <br /> L 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, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif ia." _ <br /> The applicant. c r all quit i ions. Complete drawing on reverse si fir ® <br /> Signed X <br /> - Title: Data: <br /> FOR DEPARTMEfHT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> El 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 /> FEE CK RECEIVED BY DATE PERMIT'NO, <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH'13.24 iREV.I <br /> EH 14-28 <br />