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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVE® <br /> ,j <br /> Telephone (209) 466-67$1 MAY 0 9 199n <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY <br /> I (Complete in Triplicate) PUBLIC HEALTH�SERVICESy-� i <br /> fion is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install <br /> i `�9sflArrllT"II� VI <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 t e n baquin <br /> Local Health District. ,.I PM f <br /> Joh Address 27 a o a HIL I j <br /> City Lot Size <br /> RDJJRACY RAY TARGOWSKI CONST. Address Phone { <br /> Owner's Name ' <br /> RRf]S I)pTl l Address License No. 29081 3 Phone <br /> Contractor J E.(�-I- L --- DESTRUCTION la <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ - <br /> -' _... OTHER.,.❑ — + � - <br /> - - SYSTEM REPAIR-fl� *� — f <br /> _ - . -PUMP INSTALLATION ❑ • -= PROP. LINE <br /> t SEWER LINES �DI���k— DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK _�Q�.-- PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u <br /> �---- Dia. of Well Casing <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0 R V C Specifications <br />` ]}Gravel Pack X Tracy Type of Casing <br /> LX Domestic/Private ii {] t Type of GroutNUT..-CEMEKx <br /> Cl Other Cl Delta Depth of Grout Seal <br /> i-1 Public -- <br /> i _Approx. tern Surface Seal Installed by <br /> I I Irrigation Depth I I Eas <br /> a H P State Work Done <br /> j- Repair Work Done C7 Type of Pump <br /> i{ <br /> Well Destruction Sealing Material (top 50'1 <br /> [5WellDiameter --- ;- Filler Material (Below 501 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION i I available�wi hin 20ystem 0 feet.) if public sewer is <br /> J <br /> O <br /> L Installation will serve: Residence Commercial_ Other � <br /> Number of living units: Number of bedrooms <br /> r Water table depth <br /> Character of soil to a depth of 3 feet Capacity No. Compartments <br /> SEPTIC TANK El Type/Mfg <br /> I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distancetonearest: Well Foundation P V <br /> Total length/size <br /> F LEACHING LINE El No. & Length of lines Foundation <br /> Size Property LineFILTER BED '! ElDistancetonearest: WeilNumber <br /> SEEPAGE PITS:�; -- --: <br /> SUMPS Cl Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Di§trict. <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 hall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor s hiring or'sub contraciis signature <br /> terrifies 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 /> lion laws of California." <br /> The applicant must call for all required inspections. Cample drawing on reverse sidn� m A Y 2 1990 990 <br /> Date: <br /> Signed X <br /> R DEPARTMENT USE ONLY lbv <br /> rDAreaApplication Accepted by <br /> Pit or Grout Inspection by DateFinal Inspection Date <br /> r f <br /> Additional Comments: <br /> ❑ Stk 466-67B1 ❑ 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 /> AMOUNT D�E AMOUNT REMITTED RECEIVED By DATE PERMIT NO. <br /> !FEE: CA H <br /> ♦,EH13-24MEV.r/H5) /0� � •}, <br /> EH 14-26 "� 0 <br />