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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 qft <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP R III <br /> _„„� <br /> (Complete in Triplicate) EN lr 2 7 tP°' <br /> _ yl�O�rkt�lYrlg{TJ n ed This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install <br /> }�b y t `AfLf1a,$an Joaquin <br /> made in compliance with San Joaquin Cott`ty Ordinance No.549 for.sewage or No. 1862 for well/pump and Eh t �� IP , L lF�l�� <br /> Local Health District. <br /> PM <br /> Job <br /> Job Address 23250 N. Lower ,Sacramento Rd. City Lot Size <br /> Phone <br /> Owner's Name L�CFNGI ES Address 23250 N. Lwr. Sacto. Rd. <br /> 1309031 Phone 727-554$ <br /> Contractor Address 17754 N. 88 Loekt�Ford License No. <br /> TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT 1:1 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR XX OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> "tea_ fOUNDATION_ _ AGRICULTURE WELL _OTHER WELL PITS/SUMPS` <br /> INTENDED USE y TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ClOpen Bottom ElManteca Dia. of Well Excavation <br /> T of CasingSpecifications <br /> E] Domestic/Private ❑ Gravel Pack <br /> ' ❑ Tracy, Type Type of Grout — <br /> l'1 Public C1 Other Cl Delta Depth of Grout Seal <br /> I I Irrigation —..App(ox. Depth I ) Eastern Surface Seal Installed by b well t0 code <br /> Repair Work Done XX Type of Pump <br /> H.P. State Work Done <br /> Well Destruction Cl Well Diameter Sealing Material itop 50'i <br /> Depth <br /> Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l i DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other . C <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 /> f \� <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distanceto nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property.Line <br /> I i <br /> SEEPAGE PITS 11 Depth Size -- Number ` <br /> SUMPS ❑ Distance to nearest:-- Well - - -Foundation - -Property Line <br /> ­ipISP0S;4t PONDS -�❑ _ -:'- `"-,-�'�_,::_: -._.'_°°=:�i.. :� .- =-�-�-�=4�=+per, _"—`-. ..- _.� ._ :��_. <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 Di lrict. <br /> Home ow*6rensedarenent'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 amanner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies trtify 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 The applirequired inspections. Complete drawing on reverse side. <br /> 1 Title: Bkpt Date: 09/26/90 <br /> Signed X <br /> ' FO EPARTMENT USE ONLY <br /> l � <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by_ Date <br /> )hk ! <br /> Additional Comments: ' v�"^� r s'Ta <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-.,85 <br /> P. <br /> ` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f _ <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DAF— ATE PERMIT IVO• <br /> INFO <br /> f <br /> ♦.EH 13-241REV.5/9bf <br /> EH 14-26 <br /> l <br />