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APPLICATION 1011 PI_HAL . <br /> Sir ' JOAQUIN LOCAL HEALTH DISTRICT <br /> 11e9 E. HAZELTON AVE., STOCKTON, CA ea/ <br /> Telephone 1209) 488.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is herebV male to the San Joaquin Local Health District for a permit to oonatrgd and/or install the work herein described.Thh sppacaum la <br /> made in compliance with San Jujtpiin County Ordinance No.519 for sewage or No. 1862 for well/pump and the Rules and Regulations of tits San Joaquin <br /> Local Health District. <br /> r 33 or/32 PM <br /> Job Address _�J _ City Lot Si» <br /> J� "o 9- 1 <br /> Owner's Namn��J(/1/ � - _ � Address � � - � Pis �s <br /> 1 v <br /> + [/� {� e <br /> Contract ` t1a}< Address —Lrtcme No/ ✓`'^' Phona <br /> TYPE OF L/PUMP: W WELL CJ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION U SYSTEM REPAIR fl OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE '- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial CI Open Sonom f1 Manteca Via.of Wall Excavation_ Dia. of Wall Caskg <br /> n Domestic/Private ( I Gravel Pack ❑Tracy Type of Carling Specifications _ 1 <br /> I'1 Public 1 I Other f l oehal Depth of Grout SW Type of Grout <br /> I I Irrigation __ Apmo.. Dept I I Eastern Surface Said Installed by - <br /> Repsa Work Done Ll Type of Pump H.P. Stan Wmk Dona— C <br /> Well Destruction Cal Well Diameter Sealing Material(lop 50') <br /> Depth Fgbr Material lealow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ' REPAIR/ADDITION I I DESTRUCTION 110so*Iliccs�em permuted R public aawer Is <br /> r' XOINt <br /> Installation w+ll serve: Residence±!�Commarcial_. Other <br /> Number of Wng units: _ Number of bedroofrs .. - <br /> Character o1 soil to a depth of 3 feet: Water tow dwh <br /> SEPTIC TANK I1 Type/Mfg Capacity '. No.Comparlmonts <br /> PKG.TREATMENT PLT I I _1)_'_ Method of)Or <br /> nearest:Distance to Well�— Foundation / Peap"Lin/Y- — <br /> it I <br /> Total langthlabe ,k <br /> LEACHING LINE d�No. a Length of lines _ <br /> FILTER BED I I Distance to nearest: Wee Foundation- Q-- Proo"Line <br /> SEEPAGE PITS I I Depth Si» 'T Number <br /> SUMPS i i Distance to nearest: Weil p.C) Foundation Propwly Una <br /> DISPOSAL PONDS ! <br /> I hereby utiry that 1 have prepared this application and that the Work will be dont fn accordance With San JosquM county undatartces,sup laws. and <br /> odes and ngublwns of the San Joaquin Local Health District. <br /> Nana owns a licensed agent's signature tablas the(Wowing: "I certify that M the performance of the work for wtJch dila permit is Mound.I shat rot <br /> employ any parson in such runner as to became,subject n workman's compensation laws of Ca610rMs."COMIel:f0el hkkg a sutscomm"t"tlgrssun <br /> candies the following: "I cendy that in the pafa r,m,,of the work for which this Pamir is bund.I shallemploy Paana Oaubject so workman's conOsttea- <br /> tion laws of California," <br /> Thea baa/fid must call for I iequuw, spectbm. Coinplete drawing on taverw <br /> Sgnadd k-�.(//j�.-_ Title: 'tom Date: .. <br /> _ 1l,- FOR DEPARTMENT USE ONLY ^� <br /> Application Accepted by �.x:...-�= _._ Data <br /> by i�>rDate <br /> � <br /> Cor Grout Inspection bV�� / <br /> Additional Comments: <br /> C.1 Stk 4868781 (- Lodi 3693621 U Mantas SM 7101 U Traci 8368385 <br /> Applicant• Return all copies 10: Envinon eartai Heath Panut/Saviors 1601 E. Hanlon A".. P.O. Box 2009. Stk.. CA 0=1 <br /> ". i <br /> IEE AMOUNT DUE AMWINT PFMITTED aSH RECEIVED aY DATE PERMIt No. x <br /> INiO E� G <br /> POP <br /> f w N 1a --- <br />