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APPLICATION FOR PERMIT x E. K r� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ERh E C E <br /> 1601 E. HAZTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 JUN 2 2 1990 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE NVIRQNMENTAL HEALTH <br /> Application is hereby made to the San Joaqui (Complete in Triplicate) PERMIT/SERVICES <br /> n 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 <br /> f 4 <br /> City Lot Size PM <br /> I � <br /> Owner's Name Address <br /> Phone <br /> Contractor t� dress �' �Jc7Q nse No vI � L ^.3tts�fa <br /> TYPE OF WELL/PUMP; Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONTSYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES *. '" <br /> fDISPOSAL-FLD.. . _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI[CATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca " Dia. of Well Excavation <br /> e Dia. of Well Casing <br /> [I Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public ❑ Other ❑ Delta Depth of Grout Seal <br /> I i Irrigation Approx, Depth I 1 Eastern Type of Grout <br /> ­Approx. Seal_Installed by <br /> Repair Work Done Type of Pump �p - <br /> s`ra'x—, H.P. —(� �' State Work pone_ <br /> Well Destruction ❑ Well Diameter Sealing Material (t;op 50') <br /> Depth Filler Material (Below 50'1- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I ] RESTRUCT•ION I'1 INo 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: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG.*TREATMENT PLT. ❑ � <br /> Method of Disposal <br /> Distance to nearest: Well Foundation1 w <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines } <br /> FILTER BED ❑ DistTotal length/size <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 1 I Depth Size <br /> -� Number <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 thewort <br /> employ any person in such manner as to become subject to workman's compensation laws oof Performance <br /> Contractoor r's hiring or ub-c ntracermit is tnglsignaltnot <br /> urre <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, <br /> tion laws of California." i shall employ persons subject to workman's compensa <br /> The applicant must_g0L1Jpr all requireVnspections. Complete drawing on reverse side. ° <br /> Signed X <br /> - -- -Title:� ` �.,.�.^�..-^.. �-^ <br /> Dated — <br /> FOR- ARTMENT USE ONLY <br /> Application Accepted by Z ,� <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date ? /o r/C7 <br /> Additional Comments: <br /> Cl 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24 iREV.1 i n 51 <br /> FH 14-26 <br /> _ r <br />