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APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT �S <br /> 1601-E. HAZELTON AVE., STOCKTON,. CA GtJeQ� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i n (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora _ <br /> made H compliance with San Joaquin County Ordinance No.549 far sewage:rr No. 1�forcwell�p' andinstall he Rules rk and Regulations of the San Joaquin <br /> Local Health District. i r. tpr <br /> rein T pplication is <br /> Job Address '� N. HI IKLEY STOCKTON <br /> City Lot Size PM <br /> Owner's Name B CARLTON . <br /> — ROBINSON Address 3159 POLK WAY Phone 1-1 6 <br /> Contractor VF TTIaR pj ( [�_ AddressLO-35—s—AMORA SM AWS- <br /> TYPE OF WELL/PUMP; License No. 2Q2�_Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SY ,EfN'REPAIR ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK OTHER 13SEWER LINES `- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION, +. + A ICUGTU WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM A PITS/SUMPS <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial '❑ Qpen Bottom anteca— -*Dia'of Wefl Excavation�y � - <br /> "Dia. of Well Casing, <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of Casin <br /> ❑ Public —.__ g Specifications <br /> ❑ Other LJ Delta Depth Grout Seal ' <br /> ❑ IrrigationApprox. Depth ❑ Easter _"""�"Surface Se nstaffed by Type of Grout <br /> Repair Work Done ❑ Type of Pump 1 H.P. <br /> Slate Work Done <br /> Well Destruction ❑ Well Diameter 9 <br /> Sealing Material {top 50•} , <br /> Depth x Filler Material (Below 50') r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION !No septic system permitted if public sewer is <br /> Other <br /> Installation will serve: Residence Commercial d vailable within 200 feet.) + <br /> Number of living units: Number of bedrooms' 6 <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth I <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � <br /> Method of Disposal a <br /> Distance to nearest: Well Foundation l <br /> Property Line n <br /> LEACHING LINEt <br /> ❑ No. & Length of lines <br /> FILTER BED Total length/size t <br /> ❑ Distance to nearest: Welln <br /> Foundation Property Line � <br /> SEEPAGE PITSt <br /> ❑ Depth Size Number ' <br /> SUMPS ❑ Distance to nearest: WellFoundation ..• �-,•. _ -,.--_. <br /> Property <br /> DISPOSAL PONDS F-1LineLine <br /> I 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 District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject fo workman's compensation"laws of California:"'CiSrifrac'toYs 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 California." <br /> The applicaptoust call for ail requirepHnspe.ctions. Complete drawing on reverse side. <br /> Signed XTitle: ' RES DENT <br /> Date: _ 7/2/87 _ <br /> FOR DEPARTMENT USE ONLY � <br /> Application Accepted by <br /> Date / A <br /> Pit or Grout Inspection by ✓ d��' Date"` <br /> Fin Inspection by Date p <br /> Additional Comments: rG V (.(. er' / <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY RM <br /> DATE PEIT`NO. <br />•+ EH 14-24(REV,1/851 ��6 3�D ' <br /> EH 1428 <br /> ��- 7 <br />