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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELFON AVE., STOCKTON, CA <br /> Telephone (2091466-6781 <br /> _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) .Thil ;cation is <br /> rmit to construct and/or install the <br /> the Rork and R 9ula^ons of Itle San Joaquin <br /> Joaquin county Ordinance No.SCS for sewage or No.18621or well/pump <br /> gpplication is haleby made to the San Joaquin Local Health District for ape <br /> made in compfrancs with San <br /> lea Local Health District. PM <br /> CityLot Size <br /> Job Address ,1�Q!) C/ Phone �— <br /> Address a f1 3; <br /> Owner's Name -s�-x`-�"` Y7.L� Fnone.� <br /> n am No. <br /> 2k__E S�Or/t� <br /> Address DESTRUCTION <br /> Conbactol ^'�` NEW WELL ❑ WELL REPLACEMENT ❑ OTHER ❑ <br /> �!! TYPE OF-"WELL/PUMP. SYSTEM REPAIR ❑ PROP.LINE <br /> ,) PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FCO. PITS <br /> DISTANCE_ O NEARS$T: SEPTIC TANK OTHL-R WELL <br /> FOUNDATION AGRICULTURE WELL <br /> TYPE PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well rasing <br /> INTENDED USE ❑Manteca Dia.of Well Excavation�� Specifications <br /> ❑Industrial ❑Open Bottom f Casing <br /> Type o �� - <br /> ❑Gravel Pack ❑Tracy Type of Grout - <br /> []DornsCl:/Private fl Delta Depth of Grout Seal �.�--- <br /> r ❑Other Surface Seal Installed by <br /> fl Public <br /> _Approx.Depth 1 I Eastern State Work Done_—�— <br /> n I I hr;g W T pl Pump H.P.-- <br /> H <br /> Repair Work Dona 0 Well <br /> Sealing Material(too 509 <br /> Wall Desuucuon ❑ Well Diameter <br /> Filler Material IBelgw 50'1 <br /> Depth�� DESTRUCTION I I (Nail bllelwbMn 200 feet) d it public Wwar Is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION <br /> �Commerclal_ Other QQ��11 <br /> Installation will serve: Residence Watar table dePlh <br /> Numberol bedrooms Humber of II soil uniu: No. Companmennt <br /> a. Chatactm of soil to a depth of 0 lest: Capacity_ <br /> SEPTIC TANK ❑ Type/Mfg Method o1 Disposal <br /> PKG.TREATMENT PLT.❑ Foundation_ <br /> PropenY Line --� <br /> Distance to nearest Wcll <br /> r.. Total length Size 1� <br /> tie J F <br /> .1� p No.S Length of lines / PmpenV Lim <br /> ''iI LEACHING LINE f0 Foundation_3s2— <br /> ;�. FILTER BED <br /> ❑ Distance to nearest: Weil <br /> Number <br /> W Depth Size Q Properly Line <br /> SEEPAGE PITSl <br /> Or Foundation - <br /> Ll Distance to nearest: Well <br /> ). SUMPS uin county ordinances.'tat.laws, end <br /> i. DISPOSAL PONOS [ <br /> 4 this appbcetion and that the work will be done in accordance with San Joaq Permit is Issued,I shall not <br /> 1 hereby canity%hat I have prepared uin Local Health District. performance of the work for*'rich this pe nature <br /> r_ rules and regulations a1 the San Joaquin g:" ceM1if that in the pe <br /> Home owner or licensed agent's signature centiles the following: y nation laws 01 Calilom;a.^Contractors <br /> hiring or sub<ontractin9 signature <br /> rmit Is issued,1 shall employ persons subject to workman's corapens..' <br /> .I employ any parson in such manner as to becorn subject to workman's comps <br /> canities the following:"I canity that In he performance of the work for which this pa <br /> tion laws of California." mn,d inspections- <br /> Meant must call for a ray coons.Comdata drawing onar`'^e`sida. — Late: <br /> ''. The app —�_ <br /> Title: �`(//) <br /> Signed x FOR DEPARTMENT USE ONLY <br /> _ Area <br /> Date <br /> pppli�auon Accepted by -' +CCG /y� FAat by -7 <br /> f or'grout Inspection by I "Ir �y <br /> ❑T Y <br /> ` Additional Comments: ❑Lodi ,�X21 ❑ Manteca B23 7101 P.O. Box 2005,Stk., G�95201 I V 11 t 1� <br /> ❑Stk 465 6781 ;es to:Environmental Health Permit/Service'1601 E.Hazelton Ave., <br /> Applicant.Return all cop <br /> _ K 0.ECEIVED 9y DATE PE0.MIT'NO. <br /> FEE AMOUNT DUE AMOUNT 0.EMITTED �� <br /> INFO /v'/��� J, <br /> � OZI <br /> . <br /> IN 1)N I1"'.r�^a' <br /> n <br /> c,r <br /> fN N']e <br />