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���n <br /> ~..~ <br /> ~� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUI14 LQCAL:HEALTH DISTRICT <br /> 1601 E. HA2ELTON AVE., STOCKTON, CA <br /> -1YEAR1FROMMATE ISSUED"PERMIT EXPIRES/ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.,Ths application is' <br /> made in compliance with San Joaquin Cc-unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Dikrict. <br /> Job—A-ddress City Lot'Size PM <br /> -.Owner'sName Phone <br /> Contract r <br /> TYPE OF WELL/PUMP: NEW WELL El WELL'REPLACEMENT ED DESTRUCTION 0 <br />| <br />` <br />[ INST4LLATION CN� SYSTEM REPAIR-3- OTHER 0 <br />� pnop uws <br />� pnumoxnom AGRICULTURE WELL OTHER WELL— PITS/SUMPS <br /> . .,.E,~^~ .~^ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial El Open Bottom D Manteca Dia. of Well Excavation --Dia. of Well Casing <br /> El Domestic/Private' El Gravel Pack El Tracy' "Type of Casing Specifications <br /> E] Public 11 Other C1 Delta Depth of'Grout Seal Type of Grout <br /> � ..�~~. --~__ <br /> rox. Depth [I Ebstie-rn i Surface Seal Installed by <br /> Repair Work 6one" 'Q­- Type of Pump H.P.4�Z" 10 State Work Done 9%all-. -A'11" <br /> Well Destruction—, El Well Diamet�r Sealing Material (top 501 <br /> Depth Filler Material (Bel6w 50­­ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I-] �REPAIR/ADDITION El DESTRUCTION 71 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ill <br /> � .~~ a~~. ~~ ~..~ Residence- Commercial— Other <br /> / <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet! Water table depth <br /> SEPTIC TANK n Type/Mfg_ Capacity No. Comoartm�'nt.s <br /> 411PKG. TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: Wellr­� F,Ldation Property Line <br /> LEACHING LINE E No. & Length of lines Total-length/siz <br /> FILTER BED 0 Distance to nearest: ',will Foundation Property Line <br /> ` SEEPAGE PITS t-El onnm ' Number <br /> SUMPS' <br /> O Well Foundation Prop" Line <br /> DISPOSAL PONDS 0' <br /> � prepared this application anh that the work will be done in accordance with San Joaquin county-ordinance's, state laws, a"(,---� <br /> rules and regulations of the San Joaquin' Local Health bistrict. <br /> ' Home owner- '—licensed - performance of the work for which this permit is issued, I shall not <br /> ~— signature <br /> ,J certifies subject' - 't6 workman's compensation laws vfComomia <br /> employ any person in such <br /> manner as <br /> come <br /> ."Contractor's hiring or sub-contracting signature <br /> certifies the~~_. .~~~, .~`...~ <br /> ` compensa- <br /> tion laws"f California." <br /> The applicant <br /> ^Signed)c- Date: <br /> -FOR DEPA NT USE`0 LY <br /> / <br /> Application Accepted ov ' <br /> Date <br /> � <br /> Additional Comments. <br /> / OSt* 466-6781 ` o Lodi 369-362 [] Manteca 823-7104 o 835-6305 � <br /> Applicant Return anvnn�o«xwm <br /> c� Amen�| Health Pnnnxm <br /> /emmm ,mm E. *ocoubn Ave., P.O. Box 2009, em, oAsmuoI . <br /> AMOUNT DUE AMOUNT REMiT-rED RECEIVED BY <br /> / - <br /> � -DATE - ` <br /> ~ e+13-24 fRm.`/^ <br /> EH 14-25 <br /> ^ � <br />