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APPLICATION FOR PERMIT P AY M ENr <br /> SAN JOAaU1N LOCAL HEALTH DISTRICT RI=GEIVwED <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA SEP 2 1988 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � NME <br /> �NVIRONTAI. HEALTH <br /> [[Complete in Triplicate} �' ' ipERM1TIS1:MUS <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 Ryles and Regulations of the San Joaquin <br /> Local Healih District. <br /> Jab Address _f� �` �' "� r_' ,,. _{ City I <br /> Lot Size v PM <br /> 1 ...4,,, _.t. . ► Y ,., <br /> Owner's NameAddress 6 -Phone a � <br /> ContractorAddress[ License No.��'� Phone-129— <br /> TYPE <br /> hone —TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER lr <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br />'{ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ,%(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---4pprox.,Dep h ❑ Eastern Surface deal Installed by <br /> Repair Work Done <br /> LJ of Pump H.P.I t it Stote W rk Don <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Z'y <br /> Depth Filler Materia[ (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is Q <br /> available within 200 feet.) <br /> . 1 <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 V� <br /> PKG. TREATMENT PLT- ❑ �w• Method of Disposal <br /> I <br /> Distance to nearest: Well Foundation Property Line ' <br /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size , <br /> FILTER BED ❑ . Distance to nearest: Well Foundation Property Line = <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Found9tiion x Propertyine' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done^,in accordancewith 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:,''[,.certify,that in.the performance-of the work4or which this permit is issued, I shall not <br /> employ any person in such manner as to become subjedt to.`workmans compehsation,laws of.California." Contractors hiring or sub-contracting signature <br /> k 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." F; <br /> The applicant ust I for all required inspections. Complete drawing on rev side. <br /> t <br /> Signed Title: 02 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ('/a7y Area 4 <br /> Pit or Grout Inspection by ate Final Inspection by ((( _ Date 16 w <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE , AMOUNT REMITTED C RECEIVED l3Y DATE PERMWNO. <br /> 13-24(REV.1/85) ':' .'� ' <br /> o. <br /> h � <br />