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°°'APPL�CAT.ION 'FOR PERMITc - <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT yg(f <br /> a : <br />` 1601 E. HAZE,I ON AVE., STOCKTON, CA <br /> R <br /> Tele hone"(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUL 19 1988 <br /> F (Complete in Triplicate) ENVIROM <br /> �PM ��� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th 1 application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the u es f the San Joaquin <br /> Local Health District. <br /> T31 <br /> Jab Address (72 <br /> - City PM <br /> Add ss C ! ' o <br /> Owner's Name d f <br /> Contractor s /" �r✓u { 1 a <br /> License No/62-37- Phone <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ `.OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ::FOUNDATION AGRICULTURE WELL OTffR 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 /> ❑ Public l3 Other 'n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx.-Depth-.--[-]-Eastern, Surface Seal Installed by <br /> Repair Work Done �ype of Pump, -'N State Work Dane V/11 <br /> Well Destruction .0= Nell Diameter r ' Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l:] REPAIR/ADDITION L] DESTRUCTION l I (No septic system permitted if pubiicsewer is <br /> available.within 200 feet.) <br /> Installation will serve: Residence_ Comfnercial_ Other <br /> Number of living units: Number o bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth v <br /> SEPTIC TANK ❑ Type/Mfg ACcity No: Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Foundation Property.Line r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size' V <br /> FILTER BED ❑ Distance to nearest: ell oundation Property`.Line !Y1 <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS ❑ Distance t /nearest: Well Foundation Property Line <br /> 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 icense gent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> employ an person in suc manner as to become su ' t to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies a following:"1 c ty that in It r n of the work for which is permit is issued,I shall employ persons subject to workman's compensa- <br />'h tion to of.California." <br /> The a iicant st or all equ' ti s. C e drawin n re rse s' •- ` � � <br /> Signe Tit] Date: - <br /> 0 ' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 11 Date Area 2 <br /> ZV <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-MS <br /> Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO J�� CASH i <br /> ♦.Hi 13-24(REV,i�N 51. ��. bID" <br /> EH 14-26 <br />