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Ir APPLICATION FOR PERMIT (1 <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> + 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED ; <br /> f. (Complete in Triplicate) <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 <br /> Local Health District. well/pump and the Rules and Regulations of the San Joaquin <br /> Job Address 2055 WEB$ STOCKT <br /> City Lot Size V PM <br /> 4. Owner's'Name 58 Address 2055 WEBB - - Phone462-7057 <br /> r <br /> -Contractor VF:ZTE PLBG_ -eo- Address 1:0'- �. •. AURURAs ST 202228 46,'-1 706 <br /> TYPE OF WELL/PUMP: - L.-icense No_ - Phone <br /> "-'1_w ,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Ll Domestic/Private Q ck Gravel PaQ Tracy T Dia. of Well Casing <br /> ype of Casing <br /> " ❑ Public ❑ Other I �= Specifications <br /> ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation r Type of Grout Q <br /> _Appror x.:Depth i]_Eastern . Surface Seal_Installed.by <br /> Repair Work Done ❑ Type of PumpF�H.P. (� <br /> r" State Work Done <br /> Well destruction ❑ Well piameter $$ e.Baling Material (top 50') l p <br /> Depth I 4Fillec.Material-(Below 50'} t/ i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION I (No septic system permitted if public sewer is <br /> Installation will serve: Residence iFCommercial available,within 200 feet.) <br /> Other f <br /> Number of living units: N.mber of bedrooT } i <br /> ms ^ ; <br /> Character of soil to a depth'of.3.feet:. . �hlv - <br /> SEPTIC TANK Water table depth <br /> X5V - /Mfg CapacityNo!Compartments <br /> PKG. TREATMENT PLT. ❑ � i <br /> .'»+ ; I Method of Disposal ,J <br /> Distance to nearest: Well __ Foundation . .`� Property Line I <br /> LEACHING LINE ❑(.,-Nof & Length of lines � F <br /> � Total length/size" <br /> FILTER BED ❑Distance to nearest:---.-1I ?ff I . <br /> I r Foundation Property;Line <br /> 1 � Y <br /> SEEPAGE PITS Depth Sizer f " Number:• ` <br /> SUMPS ❑ Distance"totnearestVVell - <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 District. <br /> Home owner or licensed agent's signaturercertifies 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 became 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 California.- <br /> The ap licant st call for all r quired inspections. Complete drawing on reverse side. <br /> Sia ed x Title: PRESIDENT" <br /> [ # Date: 3/24/87 j <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ^1 <br /> Date <br /> t Area <br /> Pit or Grout Inspection r F! Date Final Inspection by C� Date J43 I <br /> Additional Comments: <br /> ❑ Stk 466-6781 Q Lodi 369-3621 # ❑ M nteca 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 <br /> IO AMOUNT DUE ; AMOUNT REMITTED RECEIVED BY <br /> jDATE PERMIT No.EN 13-241REV. _EH 14-26 E5 so �tJ � —q O tq <br />