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4 APPLICATION FOR PERMIT <br /> v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA ,111 a <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED APR 24 1989 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hqr­erein described.This application is <br /> made in compliance with San Joaquin -u'nty Ordinance No. 549 for sewage or No. 1862 for well/pump an��'R n�egulaM �ilo�[fie.'.San Joaquin <br /> Local Health District. � ff � ✓1//,1� "—� ��eeSrvr�� r <br /> Lot Size PM <br /> Job Address MIA <br /> ty�i <br /> ��/ gq11 <br /> L[ �" Address 6 �" hone <br /> Owner's Name i v <br /> Contractor <br /> Address 'tense No.. -PhoneTYPE OF WE8��FWPELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST, SEPTIC TANK _oAllf SEWER LINES <br /> DISPOSAL FLD. 111911P. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE- ' —TYPE-OF WELL + PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �l Industrial ❑ Open Bottom ❑"Manteca Dia. of Wel! Excavation <br /> Dia. of Well Casing <br /> 7 e of Casin P Specifications } <br /> !� <br /> Domestic/Private 9 Gravel Pack 19Tracy Yp g � Type of Grout �jx,GCk_J <br /> F1 Public CI Other FI Delta Depth of Grout Seal <br /> I I Irrigation �.Approx.iDepth i I Eastern Surface Seal installed by • <br /> Repair Work Done ❑ Type of Pump H.P. r State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth P Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/,ADDITION l I DESTRUCTION I I (No septic cystithin m rmiittted if publicsewerisavaw <br /> I4 <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Qisposal <br /> PKG. TREATMENT PLT. © _ <br /> Distance o nearest: Well Foundation Property Line f <br /> :j <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> + Pro a Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation P rtY <br /> SEEPAGE PITS L I Depth Size Number <br /> a + Pro ert Line <br /> SUMPS ❑ Distance to nearest: Well Foundation p Y <br /> DISPOSAL PONDS ❑ <br /> ,I,herebyMcertify_1hat_I have.prepared�this application and that-the work will-be:done.in_accordance with,San.Joaqui,n.cbunty.ordinances;-state laws,_and. <br /> rules and regulations of the.San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shat! 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 /> f 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 California." 9 <br /> The appli 'n ust call for afl requir nspections. Com late drawing on rs side. 7 <br /> Title: Date: <br /> Signed X <br /> Ir <br /> RD AR ENT USE ONLY <br /> Application Accepted by Date Area�^ <br /> Pit or Grout Inspection by <br /> Date J Final Inspection by Date <br /> t <br /> Additional Comments: # <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Appficant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY /DATE PERMIT'NO. <br /> INFOQ ( l.�EH 13-241REV.1/85) : _7 �ft� 3I4� � l"\ t4 <br /> EH 14"2e <br />