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it <br /> APPLICATION FOR PERMIT ` <br /> ,a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2081 466-6781 <br /> `PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> `+ (Complete in Triplicate) <br /> lt <br /> Application a herebymade to the Sart Joa tiAn Local Health District for a permit to construct and/or install the work herein described. This SanJoan is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rales and Regulations Of the San Joaquin <br /> Local Hearth District. <br /> 39 O II Ci Lot Size PM <br /> Job Address ( • � <br /> r r . . o Phone <br /> Owner's Name Adders 3g <br /> r '/ ' <br /> 0 - ` 1 Phan - <br /> License No <br /> Cmbac AddWELL <br /> El <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> PUMP INSTALLATION U DISPOSAL FLD. PROP. LINE ` <br /> SEWER LINES <br /> DISTANCE.TO NEAREST: SEPTIC TANK.., AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION ~ t1 tai <br /> ��' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED y.15E Dia. of Well Casing d <br /> ❑ IMustrial ❑ Open Bottom ❑ Manteca Dia. of Well Eacevation . <br /> O Tracy Type of Casing Specifications <br /> ❑ oomestic/Priya O Gravel Peds Depth of Grout Seal Type of Grout <br /> M lfubua <br /> y(' n Other ❑ Delta <br /> ` _Approa: Dei I-I Eastern Surface Seal Installed M <br /> 1 Irrigation _ Stye Work Dafte <br /> H.P. <br /> �flepart Work Goner ❑ Type al Pump. <br /> , WeµDesbtrctiott O Werk Dirrtater Sealing Material Imp 50'I <br /> ( Material lBelow W0 <br /> t 9' rmitted if public sewer is' <br /> TYPE OF SEPTIC WORK: NEW INSTALlAT10N'19"YtEPA1R DDITION DESTRUCTION I 1 (Nodseblep wrlOO feet 1 <br /> Installation wig serve- R4sid'erice ^C°n°^ercial _./}Other <br /> Number of Wring units: Number of pitta fS.�y <br /> -„ Water table depth <br /> t Character of wit ma depth of 3 feet:_ No. Compartments <br /> SEPTIC TANK G Type/Mfg Capacity <br /> Merited of Disposal <br /> PKG. TREATMENT PLL-0 <br /> Distance to nearest: Well_-- Foundation Property Lim <br /> LEACHING LINE J ❑ No. S Length of Imes Total length/ <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lim <br /> t <br /> Number <br /> --Sa <br /> SEEPAGE PITS �.. I I Depth e e <br /> r Line - _ <br /> SUMPS l` Distance to nearest: Well Foundation Property .1 <br /> DISPOSAL PONDS LJ - <br /> ' - I hereby certify that 1 have prepared this application and that the work will lib done in accordai with San Joaquin c&n orordirunces.state law8,erM <br /> rules and regulations of the San Joaquin Local Health Di3rtict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the petfo[marrce of the work for whidh'lhis permit a issued, 1 shall not <br /> amptoy any person in such manner,as to become subject to workmen's compensation laws of California.- Contractbt's hiring or sub-contracting signature <br /> certifies the following'. "I ceMty that in the performance of the work for which this permit is issued.1 shall employ perwris.subject-to workman's compensa <br /> ftion laws of Cali nia." ., <br /> Tire applicant mu c fon all re firedns tions. Co`mplet�r=wnng on reverse yds pp <br /> ly\�/ 9+-� Date: ` — <br /> 1 Signed X_ Tale:.\ . <br /> 'FOR DEPARTMENT USE ONLY <br /> t Area <br /> • - t' Date � <br /> - Application Accept6_`�. <br /> Dat lwtel Ittspecgon b`-' ate a -n <br /> t Ins h,;. <br /> n _ <br /> A tonal Com ter: <br /> ❑ Stk_ 466-Ml ❑ Lodi 3 3621 ❑ Manteca 823-7101 ❑ Tiasy 1fKi669B6 <br /> I` Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave::P:O.'Bo%2009-5Utc;CA 95201 <br /> ' NW AMOUM DUE AMWNT REMITTED CASH RECEIVED BV GATE PERMIT NO. <br /> )A) TA/V� a g -wn <br /> 1 •.Hi t}z4 tRN..;x s� 7v <br /> t / Ea 142% <br />