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APPLICATION FOR PERMIT <br /> f� ��a > N JOAQUIN LOCAL HEALTH DISTRO PAYMENT <br /> — SANJOAQUIN LOCA ItEALTH DISTRIq901 E. HAZELTON AVE., STOCKTON, CA RECEIVED <br /> __EWIRONMENTAL HEALTH DIVISION Telephone (209) 466-6781 <br /> _S.CJ. LU FERM1T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 1.2 1988 <br /> (Complete in Triplicate) fINVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal the . This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the a t e San Joaquin <br /> Local Health District. Z D <br /> Job Address q lM�-,�'`�' w�sl, At C/r.,,,l .fr /1/ City-�1� YCxD/y Lot Size P <br /> Owner's NamLeDl`L�l �L��//O Address /-M� 1✓- f/�i�l�(f �S/GCee;&,,,7, Phone d <br /> Contractor �t(/i4-G Are re �/17L1�f�;l y�i <-/Y' License No.SV1 7 Phone�f l!a<'•7 <br /> TYPE OF WELL/PUMP: NEW'1/4/Address <br /> 89: WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION >t SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2_J_ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n ('✓V <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �J <br /> ❑ Domestic/Private [&-Gravel Pack r ❑ Tracy Type of Casing /E e-- Specifications <br /> (-1 Public N Otheftf/41172 " (-1 Delta Depth of Grout Seal _Qr !/ Type of Grout futc& _ <br /> I I Irrigation _Approx. Depth I I EasternSurface Soul Installed by <br /> Repair Work Done U Type of Pump �/V�m H.P. Z'2� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. [_1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Ll Distance to nearest: Well _ Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS I <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 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 Californi .' <br /> The applicant mu call fo aaH'Y' Inspections. Complete drawing on verse title. <br /> 1-- <br /> Signed X '7 / Title: / f-t��N f/.� - Date: r <br /> FOR DEPARTMENT USE ONLY p p� <br /> Application Accepted by Date 9—��-0 O Area <br /> Pit or Grout Inspection by(( /�/J/-�/ �,y,Dale /J,,Fiinalll Inspection by o�J Date <br /> Additional Comments: JIP ' ,I(.�/ `� 17`- �/NL-/��/97t� LGJ�L. ��//fyLC/r�� Oa Y.f7 <br /> O Stir 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> ♦ EH 13.24(REV.r/n51 <br /> EH 14 28 <br />