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C. <br /> y � <br /> APPLICATION FOR PERMIT ,7 <br /> Er— �e 0.t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t l" 1601 E. HAZEL T ON AVE., STOCKTON, CA P <br /> Telephone (209) 466-6781 } <br /> MAY 1 S 1990 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> i. (Complete in Triplicate) ENVIRONMEWALHEALTFI <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andLor install the work hPW"ffMRV1d§§pplication is I <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 /> l <br /> Job Address J�3 60City © `Tot Size PM <br /> Owner's Name ,d4ks rLti1f'� r A �O! dV �' I LdQ-Le- <br /> � dress - Phone <br /> - r <br /> - p <br /> Contractor � Address %;L 7,o <br /> rLicense No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK it• SEWER LINES" � 4- � DISPOSAL FLO. PROP" LINE i <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 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other ❑ Delta "Depth of Grout Seal Type of Grout <br /> —.-- <br /> I I Irrigation ­Approx. Depth J I Eastern Surface Seal Installed by <br /> Repair Work hone XJ Type of Pump H.P. State Work Donei, We <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50 <br /> Depth Filler Material'(Below 50') __ + <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I"1 REPAIR/ADDITION I I QESTRUCTION I ] {No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial= Other.. 1JJ <br /> Number of living units: Number of bedrooms Fv: A <br /> Character of soil to a depth of 3 feet: ` t v'_ ''..:"N' <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments <br /> PKG. TREATMENT PLT. ❑ s Method of Disposal f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Tota! length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` <br /> SEEPAGE PITS 11 Depth _' ""Size ' " - ' _ Number I <br /> SUMPS ❑ Distance to nearest: (Nell" .— - Foundation. Property Line <br /> DISPOSAL PONDS ❑ _ w, <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 r <br /> rules and regulations of the San Joaquin Local Health Di?trict. <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 /> 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 applica ust cal or all required ins ns. C plate rowingZonmrse side.Signed X Title: QC _ Date G r <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by bate �` ! U Area ;2 I <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l <br /> Applicant- Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVER BY DATE PERMIT'ND. <br /> +.EH 13-24(REV.riH5f <br /> EH 14.26 <br />