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APPLICATION FOR PERMIT <br />SAN JOAQYIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 herein describedThis application b <br />made in compliance with San Joaquin County Ordinance <br />Local Health District. <br />No. 50.9 for sewage or No. 1862 for Well/pump and the Rubs and Regulations. the San Joaquin <br />Job Address Z30 <br />/ <br />AJ /� <br />--�_/City/—oQZ Lot Size PM <br />Owner's Name <br />Address % <br />Contracts <br />A,,Phone <br />C(LCe(ILL- �,dlfresskLL � <br />p <br />� 7(J <br />TYPE OF WELL/PUMP: <br />LI�Dcense No. Phone 'GO <br />NEW WELL ❑ WELL REPLACEMENT ❑ <br />DISTANCE TO NEAREST: <br />DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER���✓/ ,QMH <br />SEPTIC <br />TANK SEWER LINES 'Q'X��� r AJ <br />DISPOSAL FLD. <br />PgOP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />_ <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Wall Excavation <br />❑ Domestic/Pr'Ivate <br />❑ Gravel Pack Drs. of Welt Casing Tracy Type of Casing <br />❑ Public <br />Specifications <br />❑Other ❑ Delta Depth of Grout Seal <br />❑ Irrigation <br />—Approx. Type of Grout <br />Depth ❑Eastern Surface Seal Installed by <br />Repair Work Done ❑ <br />Well Destruction El <br />Type of Pump H. P. State Work Done �" r <br />Well l�r/� <br />Well <br />Diameter .s 50') f Sti -�= est <br />mop <br />Depth F.II tefldfi8erw 50') --:5�-A� <br />eya.mn permitted a public sewer is <br />Installation will serve: Residence _Commercial _ Ot <br />available within 200 feat.) <br />her <br />Number of living units: _ Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK ❑ Type/Mfg Water table depth <br />PKG. TREATMENT PLT. ❑ Capac No. Compartments <br />Method of Disposal <br />Distance to nearest: Well Founded n <br />Property Line <br />LEACHING LINE ❑ No. & Length of lines _ <br />FILTER BED ❑ Distance to nearest: Well <br />SEEPAGE PITS ❑ Depth Size <br />SUMPS ❑ Distance to nearest: Well <br />r.,�.,...... _ Foundation <br />Total <br />Property Line <br />Number <br />I hereby certify that I have prepared this application and that the work will be done in accordance wit <br />rules and regulations of the San Joaquin Local Health District. h San Joaquin county ordinances, state laws, and <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 California. <br />The applicant must call for all required insComplete drawing onreverseside. �p 2 <br />Signed �/ Title: 8/944--- <br />Date: <br />USE ONLY 2 <br />Appli tion Accepted by D <br />�- / Area _ / .9' <br />Pit or Grout Inspecti y Date V%117&r7 Final Inspection by Date <br />S' <br />Additional Comments: /� <br />❑ Stk 468 -Ml ❑ odi -3621 ❑ Mont 1123-71 11 Tre <br />Applicant - Return all c 835-6Mopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk 962W, <br />FEE AMOUNT DUE AMOUNT REMITTED <br />INFO ;RECEIVED]BIll', DATE PERMIT'NO. <br />•EH f3N IBEV.i esf •�J rr/V <br />EH Ida! J �S. da 34b / <br />