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r <br /> h <br /> APr LICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ! , <br /> 1 ` <br /> (Complete in triplicate) <br /> Appicenon is Ietsby made to the San Joaquin Local Health Dispictfor a permit to construct and/or install the work herein described.This application is <br /> made in compllanca with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Dnuict. / V D P <br /> Job Address City_{.F-- Lot Size — Pn+ <br /> Ownar':Nameyds \\\ Phone <br /> "aad•es ^ /, <br /> �.Contractor617R caress b License No. Phone Ar <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ET DESTRUCTION <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _— DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AG.,':ULTURE WELL OTHER WELL PITS/SUMPS _ <br /> W <br /> INTENDED USE TYPE OF WELL PR06LEMAREA CONSTRUCTION SPECIFICATIONS_ <br /> _ Industrial ❑ Open Bottom ❑Manteca Dia.of Well E ruaauon Dia.of Well Casing - <br /> D Domestic/Private C Gravel Pack C Tracy Type of Casing Specif"tlons <br /> 171 Public C Other n Delta Depth of Grout Seal __ Type of Grout_ <br /> IN <br /> �I brRlabon —Approx. Depth t I Eastern Surface Seal Installed by-- <br /> A—air Work Done C Type of Pump M.P. Stare'nork Dona_ <br /> ell Destruction U Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material(Below Sort <br /> ^TYPE OF SEPTIC WORK: NE"'INSTALLATION V REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system pemtl4 it public rower is <br /> �� avadabla within 200 feet.) <br /> Installation will serve: Resida»be! Commercial_ Other <br /> E Number of living units:., Number of dreoms _ <br /> l Character of soil to a depth of 3 feet_ Water table depth_ <br /> SEPTIC TANK C7 Type/Mfg _ Capacity - No. Compartments <br /> ?KG. TREATMENT PLT.CMethod of D' ul <br /> ince to nearest: Well.��_ Foundation ,^� Property Lira _ <br /> LEACHING LINE Cl -No. 6 Length of lineszTotal length/sizer <br /> Y . Property <br /> FILTER BED ❑ Distance m mares: WellEGDFoundationline <br /> / SEEPAGE PITS I I Depth - Size___ Number <br /> SUMPS LI Data..to nearest W'sll__ Foundation Property Lim _ <br /> DISPOSAL PONDS fl _ <br /> 1 hereby comfy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulatroru of the San Joaquin Local Health District. <br /> Home owner or licensed"ant's signature unifas the following: "I unity that in the performance of the work for which this permit is,cued,1 smll not <br /> I employ any person in such manner as to become sublact to workman's compensation laws of California."Contractors hiring or subcontracting signature <br /> certdas tne loaowmp:"I url,ty thsflrlia Awmance of the work for wT lch this permit is issued,t shall employ Persons subject to wodman's companies <br /> ton)awe of Cahlotma." 11 <br /> The applicant T r or rpuietl i pe tions. Corcgat Owing on remrso side. <br /> Spend X✓ / .Tali lc iNn � 't-7 ' Dal. <br /> /,/�) FOR DEPARTMENT USE ONLY ` <br /> Apyrcaticn Accepted by%C Dat Z Area <br /> law ii BMJ♦ -, <br /> Pe or Grout Inspectiolrby Data Final Inspection by///♦• � //% /% Da[e <br /> �7 vs _ <br /> Addiltaal Comments= <br /> C S.'s 4666281 ❑ Lodi 3693621 'ffMameu 823 7104 O Tracy 875-6385 <br /> Appkunt-Return all copra to Environmental h PermiUServkea 16D1 E. Hazelton Ave., P.O. Box 2009. Stk.,CA 95201 <br /> NFOFEE AMOUNT DU.Em 2404'al-1, PatE AMOUNT REMITTED C45N RECEIVED BY D1AT�F/p7 PERMIT NO. <br /> ERN A <br /> I <br />