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APPLICATION FOR PERMIT <br /> PAYMENT <br /> r RSCEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> JUL 51988 Telephone (209) 4&6S-L794 � —`SqC)C3, 4 S,42-0 <br /> PERMIT EXPIRES 1'YEAR-FROM DATE ISSUED <br /> ]ENVIRONMENTAL HEALTH (Complete in Triplicate) + <br /> Application is hePRtlY,/A`l�at'1 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 /> Job Address 4. " <br /> ,_. City Lot Size PM <br /> Owner's Name `IT Address 1 �S`L Phone f <br /> I <br /> Contractor Address License No. Phone <br /> TYPE OF WE UMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> =�DISTANGE,-FO-NEAR EST: SEPTIC.TANK- <br /> - :SEWER LINES Z— DISPOSAL FLD. ,-.-�.- PROP:-11NE <br /> -. FOUNDATION _]_JJLQt. AGRICULTURE WELL OTHER WELL. PITS/SUMPS _ <br /> h <br /> 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 XGravel Pack ❑ Trac T e of Casin <br /> y yp g Specifications <br /> M Public ❑ Other t . Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation <br /> g" —_Approx. Depth I I East rn Surface Seal Installed by <br /> Repair Work pone ❑ Type of Pump, P. State Work Done_ <br /> Well Destruction ❑ Well Diameter I Sealing Material (top 50'1 <br /> Depth De _- t <br /> P � � Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f l REPAIR/ADDITION i.I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.i Oct <br /> Installation will serve: Residence_ Commercial— Other t7(y <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depot I'r <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 LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMP L Distance to 6earest� W611! "TM^Foundation Property Line <br /> �.._ <br /> DISPOSAL PONDS 1 ❑ <br /> on and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this applicati <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 /> certifies the following: "i certify that in the performance of the work for which this permit is issued,employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub <br /> tion laws of California." contracting signature <br /> 1 shall employ persons subject to workman's compensre <br /> The app7ua <br /> for all require inspections. Complete drawing on reverse side. <br /> Signed kllTitle:__ C 2 <br /> _ Date: <br /> 199, <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date�L� Area Y <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 11 Stk 466-6781 . Ll Lodi 369-3621 ID Manteca M-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 /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE Al RMI7 N0. <br /> + H1 -24{RpV.v <br /> EH t44-28 n5f -��` '1� 1i / <br /> E - 1 -Y ©Q � � 6 ��1 1 <br />