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fi APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y 1601 E. HAZEL ION AVE., STOCKTON, CA <br /> Telephone (209)'466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> -Application ihereby made to the Sb. -;oaquin Local Health District for a permit to construct andlor install the work herein described. This application is <br /> made in compliance with San Joaquin C,, my Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. k <br /> 4'/} <br /> Job Address 321�`-`'!._ - City I Lot Size PM <br /> Owner's Name �' '` *` _ Address Phon <br /> ,;:ansa No. , Phone R <br /> Contractor's Name ., <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEtv,,_ 'T ❑ ; D $:'R'!CTION ❑ 1 <br /> PUMP INSTALLATION D SYSTEM REPA: .''7 ETHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWL',,%- NES DISI",'41_ FLD. PROP. LINE <br /> FOUNDATION AGRICU-TURE V` T. �*OTHE' "SELL__.a�__� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL <br /> PROBLEM AREA t :TRUCN 4Z`-'IFICii' <br /> ❑ industrial ❑ Open Bottom C =,inteca sof Well Ex ?va �,` Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ y +y of Casing — Specifications V" <br /> ❑ Piabiic ❑ Other ❑ D `e u '-f Grout. ial '` Type of Grout <br /> ❑ Irrigation <br /> ---Approx. Depth ❑ Eas«;� -Nurfac +F :fled by i I <br /> Repair Work Done ❑ Type of Pump P.�.,. State Work Dona {) <br /> %r <br /> Well Destruction ❑ Well Diameter St...:ng Mi;j, trial ;s,-• �) ; <br /> Depth Filler`' 9af7;31 {Below <br />[ TYPE 0 <br /> F SEPTIC WORK: NEW INSTALLATION ❑ REdc <br /> PAIR/ADDITION DES'( ACTIO INo septic ystem permitted if p 'c sewer is <br /> �,; vailable 1 200 feetA Y , <br /> T Installation will serve: Residence— Commercial Other <br /> j <br /> Number of living units: Number of bedrooms . <br /> a �_-_ <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. ❑ Method of Disposal . <br /> Distance to nearest: Well F�`3t�dation ''_ E•rtY:�-'nP— <br /> " <br /> LEACHING LINE ❑ No. & Length of lines i — To°.'3i <br /> FILTER BED ❑ 'Distance to nearest �h-?: Fou 'ati:.a ' 't 1irty Line <br /> 'SEEPAGE PITS ❑ Depth "', 9 ;G= f� �er�--- " s .;. .• <br /> s <br /> SUMPS ❑ Distance to nearf" I :; Foundation Propert' Line a , <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application»`_.< a!1 i Vrk-will-be-done in.accordance with.San J � ruin cou��r r9inances, state laws, and <br /> rules and regulations of the San Joaquin Local He not <br /> Home owner or licensed agent's signature certifies i;A,°°Ik ung: "I certify that in the performance of the work fc rwhich this rgrmit is issued, I shall ure <br /> employ any person in such manner as to become sub) ;t to workman's compensation laws of California."Contracv,. s hiring or sub contracting signature <br /> i� certifies the following: "I certify that in the performancl of the work for which this permit is issued,I shall employ per,?ns subject to workman's compensa- <br /> tion laws of California." - <br /> The applicant must call for all required inspections. Complete-drawing-on_reverse_side. <br /> ° <br /> Signed Title: "L-ae: <br /> � <br /> FOR DEPA TMENT USE ONLY <br /> Application Accepted by Date <br /> �1i•=`+Area O <br /> Pit or Grout Inspection by Date Fin Inspection by at <br /> Additional Comments: 66 <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manta --823-7104 ❑ Toracy 835-6365 i <br /> t.. Applicant- Return all o i s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDC RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> '.+ EH 13-24(REV.10/83) "�. .� a - <br /> ! EH 14-28 <br />