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1 p, tj ��� , APPLICATION FOR PERMIT DISTRICT <br /> D �cr <br /> � <br /> SAN JOAQUIN LOCAL HEALTH , <br /> 1601 E. HAZELTON AVE., STOCKTON, CA S"P 4 1987 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH <br /> PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permconstruct and/or install the work herein described.This application is <br /> it,•to <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for woupump and the Rules and Regulations o1 the San Joaquin <br /> Local Health District. <br /> Job Address <br /> �fl fly • ( Ct!/� / / City � !� Lot Size PM <br /> Owner's Name � <br /> ���C-v' Address 6 n e� Phone <br /> C. mI y'e55—"7 License Nmz7� <br /> Contractor -� /u � Phonef <br /> TYPE OF WELL/PUMP: NEW WELL 171WELL REPLACEMENT ❑ DESTRUCTION C1 <br /> PUMP INSTALLATION SYSTEM REPAIR.e OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br />` FOUNDATION AGRICULTURE WELL OTHER WELL _— '��PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing G <br /> ,{Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public n Other P Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation --Approxi Depth I 1 Eastern Surface Seal Installed by <br /> r H p V-4- State Work Done <br /> Repair Work Done � Type of Pump -5L)'6 <br /> Well Destruction ❑ Wel! Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION Ll DESTRUCTION I 1 (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 /> r Capacity No. Compartments <br /> ❑ Te/Mf <br /> SEPTIC TANK YP g . <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> l" <br /> Distance to nearest: Well Foundation Property Line <br /> �E <br /> • Total length/size <br /> I LEACHING LINEngth. ❑ No. & Leof lines <br /> it <br /> FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS VI Depth I Size Number <br /> - SUMPS + -LZDistance+to nearest: Well Foundation Property-Line - — <br /> DISPOSAL PONDS ❑ <br /> I Hereby certify that I hav repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of an Joaquin Local Health District. <br /> Home owner or license a is si nature certifies 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 nine t0 bet6 esubiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followin . c rt y that th ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> 111 tion laws of Califo <br /> ' The applicant m t req r d spections. Complete drawing on reverse side. _ <br /> /7 <br /> Signed X <br /> Title: � ��C,- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data <br /> Area <br /> Pit or Grout Inspection by <br /> j I Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 (5 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 /> 4 - <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH lJ RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 17-24 I RE'V.i i A 57 <br /> EH 14-26 < - <br />