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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 . fir, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' �}• <br /> 5 <br /> (Complete in Triplicate) <br /> gpplicatio,Is hereby made to tills San Joaquin Local Health District for a permit to construct and/or install the work hereto :'CI+f• <br /> made in compliance with Sen Joaquin County Ordinance No.548 for sewage or No.1862 for well/Gump and the Rules and Raguletiom o1 the an Joaquin <br /> Local Health District. <br /> 9 .1/ a 9 9 City 17 / _ Lot Size /QG PM <br /> Job Address ///9 y' <br /> Phone 36 9- 240-3 <br /> Owner's Neme _Y , t- Address ' <br /> ConVector'a Name. FLO y� �'--W- -eP <br /> License Na. <br /> 'Y7 L Phone a' 7 <br /> TYPE Of WELL/PUMP: NEW WELL :� WELL REPLACEMENT ❑ DESTRUCTION C <br /> PUMP iNSTALLA510N ❑ SYSTEM REPAIR C OTHER C <br /> SEWER LINES DISPOSAL FLD.-- PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION 5PECIFICATIONS Die.of Well Casing <br /> C Industrial Open Bottom C Manteca Dia. of Well <br /> Excavation Specifications <br /> C Domestic/Private C Gravel Peck C Tracy Type of CasingDepth of Grout Seal Type of Grout <br /> C Public C3 Other G Delle <br /> C Irrigation —Approx. Depth C Eastern Surface Seal Installed' S \ <br /> H p State Work Dona <br /> Repair Work Dorm C Type at Pump --- -�� <br /> Well Destruction C Well Diameter _—_-. Sealing Material(top 509 . <br /> Depth__ Filler Material(Below W') <br /> r <br /> TYPE OF SEte <br /> PTIC WORK: NLW INSTALLATICIN C REPAIR/ADDITION DES1'RUCTP <br /> C avail bIN �e'witte hin 200%reined if public saws:is <br /> Installation will serve: Residence� Commercial_ Other 5 1/f-5L Number of bedrooms._3 Water table depth <br /> Number of living unite:_ - <br /> Character of suit to a depth of 3 feet:--;g'B41P A-dAlt No. Compartments --- cP <br /> SEPTIC TANK GR"Type/Mfg �i� _ J �"I ----Capacity <br /> Method of Disposal <br /> PKG.TREATMENT PLT.❑ y /(}d <br /> y.,,��.a/L Foundation�— Property Line <br /> Distance to nearest: Well Jam— <br /> / Af + Total leng<h/size_ S J(2 <br /> LEACHING LINE No. & Length of lines E <br /> FILTER RED ❑ Distance to nearest: Well <br /> Foundation -7-0 Property Line <br /> Depth 7'C t Sixc_�' Number �rs (- <br /> SEEPAGE PITS r Property Line <br /> SUMPS C Distance to nearest: Well�d�r Foundation�— <br /> DISPOSAL PONDS C <br /> hereby certilY that nave prepared this application and the.the work will be done in accordance with San Joaquin county ordinances,state taws,and rf' <br /> l I <br /> rules and regulations of the San Joaquin Loco[Health District certify work 10, hiring <br /> Home owner of lilictei sed agent's manner as to <br /> Inch subject the <br /> foto workmanbcompeneetipn WwrooitCalifornia h0 ontractorslh r ng or euthconitrecl�g gnletu�a <br /> employ zny Da <br /> cenifies the following:'I certify that in the paft,mance of the work for which this permit is issued, shall employ Peiwns si�Dlect to workmen's compensa- <br /> non laws of California." <br /> The applicant must <br /> I ryquirad inspectio . Complete drewie: on reverse side. - <br /> // v/n Title:_ Dare: <br /> Slpnsd <br /> FOR,DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by -- I Gf�'Oate�J�1 <br /> DateFi^al inspection by <br /> r:-Y'sp�6f�J� L +b✓�'—/ SC�GiJ (r <br /> Grout Inspection Dy <br /> it� y <br /> Additional Comments: bc-�'l <br /> 468.6781 C Lodi 369:3621 C Manterwa 823-710A [I Tracy 835'x'` A 95201 <br /> 0 Stkplic <br /> ant. Return ea cupies to: Environmental Health Permit/Services 1601 C. Hazelton Ave.. P.O. Bax 2009, Stk., C <br /> C Stk <br /> --T <br /> AMOUNT SEMITTED CK a RECEIVED BY DATE PEPMn'NO. - <br /> FEE AMOUNT DUE CASH T <br /> INFO { I 8'/1/1 <br /> I � '�raLiah Sill-ati 1S r <br /> .Ex tsx.iaEv.ratan C c o Gk.-�,. , <br /> ax,gym <br />