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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT' Kh V <br /> JUL 0 3 199r <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i Telephone (209) 466--6781, ENVIRONMENTAL HLALTH <br /> P <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUEDUMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby rn"ade to the San Joaquin Local Health District for a permit to construct and/or install the work herein=described. This applicat ion is <br /> made)n compliance with San Joaquin County Ordi,nance 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 City Lot Size PM <br /> Owner's Name Address <42 1J, ALZ�,V�� Phone <br /> Contractor VAddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL L) WELL REPLACEMENT 12 .%DESTRUCTION 0, <br /> PUMPINSTALLATIONiN_S_TALL4_TION El_ -SYSTEM REPAIR OTHER 0; <br /> SEWER LINES -4— DISPOSAL FLD.— PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> E 1).nduistrial ❑0 Open Bottom 0 Manteca Dia, of Well Excavation I <br /> 1 — .specifications <br /> X:r,Domestic/Private 0 Gravel Pack L Tracy Type of Casing1 <br /> I'] Public F1 Other ,H'Delta Depth of Grout Seal TVpe,of Grout <br /> Surface Installed by <br /> I wig��-on -Approx. Depth I (`EasternWork <br /> Done <br /> _4t <br /> Repair W A Done 11 Type of Pump �IA H.P. 1�t— State 4s,4 <br /> n�_01 <br /> Well Destruction E Well Diameter Sealing Material (top 501 <br /> e- Depth3 ~ Filler Material (Belbw 50') <br /> TYPE OFrSFPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I g DESTRUCTION 1.1 (No 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: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation— Property Line 4) <br /> LEACHING LINE 0 No. & Length of lines r Total length/size <br /> FILTER BED ID Distance to nearest: Well Foundation — Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL-PONDS-- -F4 <br /> I hereby certify that I have prepared this application and that the work will be don in accordance with San Joaquin county ordinances, state laws,. and <br /> rules and regulations of the San Joaquin Local Health D1trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in a performance of the work for which this permit is issued, I shall not <br /> employ . such manner as to become subject to workman's compensati n-laws-of-C-ahto-mia-"-Contractor's-hiririg or sub-contracting signature <br /> if�y an.y perso <br /> i..the <br /> folly <br /> n_ �, <br /> cert 9 1 certify that in the performance of the work for which this p rmit is issued, I shall employ persons subject to workman's compensa <br /> f Car <br /> tion laws , Cali or <br /> T �pp <br /> pli, t r O'S de:. <br /> The i 'all for all require inspectionvr_omplete drawing on rover d <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by A <br /> rea <br /> Pit of Grout Inspection <br /> Date Final Inspection by Data p <br /> Additional Comments: <br /> L n Sik-- 466-6781—0 C6di-3fA-3621 0 Manteca 823-7104 11 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 REMITTED CK A RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE CASH <br /> EH 13-24 IREV.1/8 5) 10,36 A0 70'0 7 50 <br /> EH 14-26 1 1 1 0 ka5_ <br />