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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 , SEP 2 1988 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - g <br /> w , • I <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here <br /> Ihtielaatlrih�"F" 1ication is <br /> made in compliance with San Joaquln 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::. i #. <br /> City ' Lot Size' PM <br /> Job Address <br /> i i C^ <br /> n Address C one <br /> Ph <br /> { Owner's Name <br /> } i�Q lGryL�!'Pf"" I✓/ LG i4tls � -r,- ense No. Phone — <br /> t Contractor <br /> TYPE OF WELL/PUMP: NEW WELL El <br /> REPLACEMENTDESTRUCTION ❑ <br /> . <br /> PUMP INSTALLAT ON ❑ SYSTEM REPAIR ❑ OTHER ❑ l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD.In?- - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing <br /> ❑ ndustrial ❑ pen Bottom ❑ Manteca Dia. of Well Excavati' `e P <br /> ravel.Pack ❑ Tracy Type of Casin Specifications f7 <br /> El <br /> T of Grout <br /> t //❑ Public Q Other' ^Delta Depth of Grout Seal Type <br /> I <br /> 1:1 Irrigation -app rax. Depth ❑ Eastern Surface Seal Installed by <br /> State Work Done <br /> Repair Work Done El Type of Pump N.P. <br /> Well Destruction I-] Well Diameter Sealing Material {top 501 <br /> 44 <br /> j P� Q�� Dep i Ma w <br /> TYPE OF SEPTIC WORK: NEW I STA ❑ REPAIR/AD (TION ❑ DESTRUCTION ❑ (Noavaseptic s stemin frmitted if public sewer is := <br /> Installation wlI serve: Residence—4 Commercial— other 9 <br /> F Number of living units: , Number of bedrooms Water table depth <br /> 77 <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments r <br /> SEPTIC TANK LlType/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> i LEACHING LINE ❑ No..&Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ElDepth Size Number <br /> SUMPS 0 Distance to nearest. Well Foundation Property Line <br /> a.. .. DISPOSAL PONDS ❑ <br /> 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 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 Califor' <br /> The applican ust call or r it inspections. Complete drawing on rev e side. <br /> Signed <br /> Title: Date: <br /> FO" PARTMENT USE ONLY <br /> Date__ Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by ata Final Inspection b CJII" <br /> 1 0 <br /> Additional Comments: IF <br /> ❑ Stk 466-6781 0 Lodi 369-3621 L3 Manteca 823-7104 ❑ Tracy <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24(REV.1/55) - .•kin r - <br /> EH 14-28 <br />