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t <br /> APPLICATION FOR PERMIT 4Ls~f il <br /> EALTH DISTIC <br /> S 601 E. HAZENi ONCAVE., STOCKTON,RCAT [Rvu E D& <br /> Telephone (209) 466-6781 NOV 10 1989 <br /> 1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hOPER d IT V'fhi11Qbllrtation is I <br /> P <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. CitLot Size <br /> Job Address Qi <br /> PM <br /> r/l�i� Address �� �' ' ��1 G <br /> Owner's Name Phone <br /> to t 7� <br /> Contractor <,. Address a License No,�� l Phon <br /> TYPE OF WELL/PUMP: NEW WELL,❑: WELL REPLACEMENT I❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION D�" SYSTEM REPAIR ,ID OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER III NES I'DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL `OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca r Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `' Specifications I <br /> 'I� Clhe <br /> Public l Or r--1Delta 1 Depth of Grout Seal ... Type of Grout <br /> -1�=Irrigation —_Approx. ,Depth I I Eastern" + Surface Seal Installed by <br /> F - - State Work Done <br /> Repair Work Done LType of Pump H.P. <br /> Well Destruction ❑ Well Diameter i� l Sealing Meierial (top 501 <br /> Depth I '4- r Filler Material-(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDI$IONJI I DESTRUCTION ! I (No septic systenhpermitted if public sewer is V\I <br /> ---"� available within 200�feet.) <br /> Installation will serve: Residence"-!--Co'mrllerci-_al� Other <br /> Number of living units: Number of bedroom'!s <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TAMC El Type/Mfg �{ Capacity No. Compartments <br /> PKG. TREATMENT PLT. El ( Method of Disposal <br /> Distance to nearest: ?Well Foundation Property Line fi <br /> LEACHING LINE E71No. & Length of lines ~�. Total length/size <br /> y FILTER BED O Distance to nearest: j <br /> k-WeII Foundation PropertyLine <br /> (` <br /> SEEPAGE PITS t I Depth 'Size Number <br /> — <br /> SUMPS L_I Distance to nearest': Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application antd 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 Healthff3iktfict. <br /> Home owner or licensed agent's signature certifies the°foNowing: `I 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 to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the perfofmanceiof the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." J - <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. F <br /> i/ 0 G": / -- <br /> Signed X_ �� ��/�`� ' Title. Date. <br /> I <br /> i FA DEPARTMEN USE ONLY <br /> Application Accepted by I Date Area <br /> t <br /> Pit or Grout Inspection by f Date Final Inspection by. r� c�,) <br /> I t <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 © Manteca 82)=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 AMOUNT DUEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br />' INFO CASH 1 <br /> + EH 13.24(REV.t i n 5] C `/�3 '777 <br /> EH 14-28 - <br />.IFF f <br />