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TV <br /> 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 1 YEAR FROM DATE ISSUED <br /> (Complete inTriplicate) <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. a _ <br /> Job Address 1720 E. ,WTLLOWr .: City STOCKTON Lot Size Y PM <br /> $ <br /> Owner's Name AMERICO CHALIS Address Phone 465-8818 <br /> ContractorVETTRR PLEGl. CO -- Address License No. 202228 Phone 463-1706 <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANC EAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �— <br /> DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t <br /> INTENDED,USE NA TYPLE OF WEL OBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial EJ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 11 Tracy Type o _ Specifica_tions <br /> ❑ Public ❑ Other _ ❑ Delta x Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �4pprox. Depth ❑ 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') <br /> DepthFiller Material (Below 501 `. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO { o septic system permitted if public sewer is <br /> I I� i vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other-- — <br /> Number of living units: I Number of bedrooms <br /> Character of soil to a depth of 3 feet: f Water table depth k <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ve 1 Method of Disposal <br /> Distance to nearest: Well,' Foundation _ 'Pr'operty Line I <br /> ��. S✓ � � '' I if' <br /> LEACHING LINE El NO. & Length of lines Total length/size k I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line { <br /> SEEPAGE PITS ❑ Depth Size" 1:: Number t t <br /> t <br /> SUMPS Ll Distance to nearest: Well 4 4-Foundation6­ Property Line.....C� � <br /> DISPOSAL PONDS ❑ I�: ,- l 'P' 4"" <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: "t certify that in the performance of the work for which-this�permit.is issued, I shall not 1 <br /> employ any person in such manner as to become subject to workman's compensation law§of California." Contractors hiring or sub-contractirid 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 applican ust call r all re�`luir inspections. Complete drawing on reverse side. / ' I <br /> Signed x �� "�— Title: PRESIDENT -'' Date: 3/20/87 <br /> F EPA MENT USE ONLY <br /> Application Accepted by k Date ` Area D <br /> Pit or Grout Inspection by Date Final Inspection hu Date 3 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Vodi 11369-3621 ❑ 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 95201 <br /> I <br /> INFO <br /> FEE AMOUNIT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. <br /> + <br /> EMI <br /> 3-24iREV.t/asi (,M✓ 35•vv �j eQ'� 3--I� �(����� <br /> EH 14-26 ✓Jf �C!O l] <br />