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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)!^ <br /> Application rs hereby made to the San Joaquin Local Heal.h Dis[rwt fore permit to construct andior instal[the work he':an described.Thb applig tiooaq is <br /> made.in compliance with San Joaquin County Ordinance No.50.9 for sewage or No. 1pM far weal/pump and the Rules and R1Igtdatlane e!the San Joaquin <br /> Local Health District. <br /> QQ /►4PI _ City �_-- Lot Size <br /> Job Address Ctt�'E d_ PN! <br /> J ���� <br /> Phone <br /> o 7 <br /> Add,—r --+� -- — r <br /> s Owner's Name. • <br /> } Phone ._ .r 9 e <br /> Contractors Name -- `eA� License No. <br /> TYPE OF WELLIPUMP: <br /> NEW WELL i WELL REPLACEMEN-77 DESTRUCTION <br /> PUMP INSTALLATION G SYSTEM P.EPAI? ] OTHER iJ <br /> y DISPOSAL FLD- PROP. LINE _ G <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> -- +{ <br /> AGRICULTURE WELL --- OTHER Vti'Eti PIT5ISUMPS <br /> FOUNDATION — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO`O UL; k SPECIFICATIONS Dia of Well Casing <br /> 1— ]Open Bottom L� Manteca Dia.of Weil Excavation <br /> 0 Industrial Specifications <br /> C,DomesticlPnType of Casingvate [7 Gravel Pack El Tracy Depth of Grout Seal Type of Grout <br /> 0 Public ©Other <br /> El Delta <br /> C Irrigation —flpprox.Depth ❑ Eastern Surface Saal installed by <br /> of Pump' H.P. <br /> Repair Work Done G Type — State Work Done -- <br /> WeII Destruction ❑ Well Diameter Sealing Material(tnP r,C') <br /> Depth Filier Material 112100w 50'l <br /> ._� <br /> .� TYPE OF SEPTIC WORK: N- INSTALLATION G RL-PAIR/ADDITION iD` GESTRUGTION avlailabple with re200 feetrcied'rf public sewer is <br /> i <br /> Installatico will serve: Residence Commercial, other <br /> Number of riving units:1 Number of bedrooms__ — Water table depth : <br /> Character of soil to a depth of 3 fee': er <br /> SEPTIC TANK Type mfg S Capacity_ /L_.1V1 No. Compartments <br /> Method of Disposal !!1-1/ <br /> PKG.TREATMENT PLT.❑ Property Line <br /> j ! <br /> �.L <br /> Distance to neatest- well Foundation��— — _ <br /> No.AA of lines Total lengthl <br /> LEACHING LIIJE �i r property Line_/�j <br /> FILTER BED C D•starr.e to nearest: Well fA Foundation <br /> IF�t)epth —Size�� Number _ <br /> SEEPAGE PITS r <br /> d Foundation Property Line w <br /> SUMPS CD Distance to nearest: Well��— <br /> DISPOSAL PONDS <br /> at I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. <br /> I hereby certify thstate laws,and <br /> rules and regulil iar+s of the San Joaquin Local Health District. he <br /> 1 Ot <br /> Home owner or lige n such agent's nna gas tocertifies becomesubjecthe tlto wo9kma 'scompensationlawsthat in the oof Cal famlahe Contractor's work for rhiringr orLub-cont act ng signature <br /> employz employ any person persons subject to workman's compensa- <br /> certifies the toliovrin9:"I certify that in the performance of the work for which this permit is issued,r shall employ <br /> tion Laws of California." <br /> The applit a ust call for all required ins ions.Complete drawing on reverse side, /1_ - <br /> S _ <br /> Title: <br /> igned Date; s.tj/f/s7 <br /> FOR DEPARTMENT USE ONLY <br /> –2. Area <br /> S Date <br /> Application Ac�Pted by c�// – <br /> pit or Grout Inspection by <br /> Date `7 Final Inspection by Data <br /> Additional <br /> Comments'. 7��(r�(!� �[(��� <br /> Stk 466 67431 ❑Lodi 36 3621 0 Manteca BV-7104 G Tracy 6385 <br /> Applicant-Return all copies tai Environmental Health Permit/Services 1641 E. Hazelton Ave.. P.O. Bax M. Stk., CA 95201 <br /> 4 CK s RECEIVED 9Y DATE PERMIT'N0, <br /> INFOFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> .EK 1124[REV.talB]I <br /> EN 1+20 <br /> 1 I <br /> r <br />