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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 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 19675 E. Milton Rd. CityLinden Lot Size PM <br /> Owner's Name Ronald J Sanguinettlgddress 18704 E. OOpperopoliS Phone <br /> Contractor Purviance Driller-%c1dTeT-J1C.VP. O. Box 64,LincJQn,, No. 377,923 Ph,,,- 887-3554- <br /> TYPE <br /> hone_ 887--3554TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation-/ 1.6 Dia. of Well Casing 160D <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy .-Type of Casing Steer Specifications 3/16 <br /> Fl Public ❑ Other f-3 Delta Depth of Grout Seal I Type of Grout <br /> - <br /> N Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material !Below 501 1�1_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet,) <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pro arty Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 District. <br /> Home owner or licensed agent's signature certifies the following: "i certify that in the performance of theworkfor 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- <br /> tion laws of California." <br /> The appliml1ust car, 11 eq ired inspections. Complete drawing on reverse side. <br /> / <br /> Signed X 1 �L i Title: President Date: 2/8/89 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by / i r Date C a� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> O 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 95201FEE ° <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH �CK RECEEIIVED BY DATE �PjERMI/7y7N0. <br /> +.EH 13-24[REV.i/x 57 �e <br /> EH 14-28 iii <br />