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APPLICATION FOR PERMIT ,JUL - 2 1984 J_ <br /> SAN JOAO.DIN'LOCAL HEALTH DISTRICT SAN JOAQUIN LOCAL <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA HEAL . <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISS I.. Vo <br /> � <br /> ?�' ,.f� rJ­V# jv;: 7;r,it:tf�_,,,i� ,.. (Complete in.Triplicate) <br /> Application 1s hereby made to the San Joaquin Local Health District for a permit to construct and/o1in 11 the vivp fi in described. TN's application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for we pum Vh the u es and Regulatipl3 San Joaquin <br /> Local Health District.;,.W',, <br /> vs I <br /> Job Address `� � �. } Ci �-C d Lade" PM <br /> Ct <br /> Owner's Name r' Address _-t.R-t S r A 57 3A#�-e �P on � <br /> Contractor's Name r License No. y 1 3 7- : 3 <br /> .TYPE OF WELL/PUMP:, NEW WELL f �" WELL REPLACEMEW-9-6DESTRUCTION <br /> PUMP INSTALLATION '❑ SYSTEM REPAIR 0'4 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> -Al 5liWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION .AGRICULTURE..WELL� OTHER--WELL- -. r PITS/SUMPS -t <br /> r <br /> INTENDED USE TYPE OF WELL yPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial pen Bottom ❑ Manteca - Dia, of Well Excavation Dia. of Well Casing <br /> @'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ _!!!t 4� Specifications <br /> ❑_Publjublic ElOther I ❑ Delta Depth of Grout Seal .S Type of Grout <br /> ❑ Irrigation est t�_IApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump Shy H.P. State Work Done ai <br /> Well Destruction Well Diameter Seating Material (top 50'} .� <br /> \ Depth Filler Material (Below 50') <br /> TYP OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) T <br /> Installation will serve: Residence Commercial Other f <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: -4- Water table depth <br /> SEPTIC TANK 1❑ Type/Mfg f i Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ fMethod of Disposal 5 <br /> Distance to nearest: Well Foundation Property Line i <br /> -LEACHING LINE ❑ No. & Length of lines Total length/size <br /> 1 <br /> FILTER BED 1❑ ,Distance to nearest: Well Foundation Property Line <br /> I � r <br /> SEEPAGE PITS ❑ *Depth Size Number <br /> ISUMPS r ❑. Distance to nearest: Well Foundation Property Line <br /> .a- - �.•,p.�� k _ - may; <br /> s 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, a O <br /> rules-and regulations of the San Joaquin Local Health District.-- x <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:"Contractors 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 emDlov nraranns subject to workman's compensa- <br /> 3 •`tion laws`of California." <br /> The applicant must call for all aquirad inspections. Complete drawing on reverse side. <br /> y .�r� <br /> Signed X� Title: s.� / _ Date: �Z <br /> •' FOR DEPAR�ENT USE UY l <br /> Application Accepted by µ Y date Area <br /> ? ..: <br /> r Pit or(9 Inspection by_ Date Final Inspection by _ '! T Date <br /> .� _4 <br /> Additional Comments: <br /> ❑ Stk-466-6781 -0 Lodi-369-3621 O Manteca 823-7104- r El Tracy 835-6386 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r r~ n <br /> FEE � <br /> i ' k <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> + <br /> �b <br /> EH 13-24(REV.]0!831 <br /> EH 1426 <br />