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APPLICATION FOR PERMIT <br /> .- , -, SAN JOAQUIN LOCAL HEALTH DISTRICTIt <br /> ` 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 MAY 2 0 1991 <br /> I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDEN.VlRONMENT L HEALTH <br /> F {Complete in Triplicate) PERMIT /SERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This 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 I <br /> Local Health District. <br /> Df <br /> Job Address S19 l I�E1' a� City Lot Size PM <br /> Owner's Name Address Phone ?f,941_17� <br /> Contractod' E 1'C Address3de Al S License No Phone 30p 1 <br /> TYPE OF WELL UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION >1, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> —_ -• — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M <br /> 1-1 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout <br /> kf Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by f _ <br /> Repair Work Done ❑ Type of Pump �:2 H.P. in State Work Done e� + <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feeLM <br /> Installation will serve: Residence_---- Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINT= ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> { <br /> SEEPAGE PITS l I Depth Size Number j <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> - -f 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: "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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- f <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: �/� Date: -3- <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> Application Accepted by a Date ,�'�! Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ 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 t <br /> FEE <br /> } <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT N0. <br /> +.EH13-24(REV. /n 5) (�A �,� '`}�)'')� f <br /> EH 14-25 ��I"`��� ] y erg.{ `� <br />