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� V <br /> ti <br /> � a APPLICATION FOR PERIa1f7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4666791 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 1. Is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to instruct and/or instill the work herein described.This application <br /> meds in compliancewith San Joaquin County Ordinance No.549 for sewage or No.1882 for""pump and the Rules arta Regulation+of the Son Joaquin <br /> Local Health District. <br /> r 7/6' <br /> A` <br /> Job Address sea 1'c <br /> N G N city'(�1A/r/iE_`cA Lot So,s <br /> q i <br /> •✓ jj gC VAUlJ Address �G y - e y/�J Phone <br /> Owner's Name l�A nn <br /> [.11G License No. ;2/�'.G� ph" . <br /> Contractor's Name <br /> -i TYPE OF WELUPUMP: NEW WELL ❑ WELL REPLACEMEM ❑ DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G <br /> ' - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PROP. LINE DISPOSAL FLD._ PRS/SUMPS <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> _ ❑Industrial ❑Open Bottom ❑ Manteca Dia.of WOR E-CA"Wrr spoci6cetbiDns <br /> of WCaa+q <br /> ?'• ElDomestic/Prbate ❑ Gravel Pack ❑Tracy Type of Coal 9 pa <br /> ❑ Public ❑Other ❑ Deka Depth of Grcu:Seal Type of GrM <br /> ❑ Irrigation _—Approx. Depth ❑ Eastehl Surface Seal Installed by <br /> Repair Work Dona ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Eller Material(Below 50'I <br /> s in <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION OESTRUCTION 11 (No septic syatern pertrbmed if public sewer <br /> ip available within 200 feet.l <br /> i� <br /> Installation will servo: Residence <br /> Commerc9al— Other <br /> Number of Wing unite:— Number of bednoana f� <br /> Cheracter of mil to a depth of 3 feet: �A � '4H f Wow table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity hid,Compare sorts <br /> PKG.TREATMENT PLT.❑ Method at Disposal - <br /> b Distance to nearest WNI Foundation Property Uih'-Ue - --1 <br /> .. <br /> LEACHING NE C No.8 Length of tinea Total to gdl//� <br /> FILTER BED jq Distance to nserest: Well FOumdafipn �C r Property Line�3e r — <br /> SEEPAGE PITS ❑ Depth Slle Number <br /> e..t SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that t he"proofed this application and that the work will be done in accordance with San Joaquin county crdinrances,stabs Iowa,and <br /> rules and regulation of the San Joaquin Local Health District. <br /> Hone owner or licensed agemb signature certifies the following:"I certify then in the perfomunce Of the work for which this pemtit is issued,14W not <br /> employ arty Person in such manner at to became wbpct to workman's wmers <br /> pation Laws of California."Connectors hiring or wDcontneting signature <br /> -cenifas the folowing:"I certify that in the perforrmance of the work for which tha permit's issued,I shell employ persona wbptt to workmm'a cerrlpena► <br /> tion laws of Caldomia.,• <br /> The applicant must call foroff inspections.Comple'e drawing on reverse side. / <br /> Signed% -r/C�C.� Tale: Dace: _!T <br /> /FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> iVYl.h — Dan Wit-- Ane l3 <br /> Ph of Grout Inspection by 'V Dabs do <br /> Final Inapacn W r s+6l^"— Dan L <br /> Additional Commenter <br /> i C Stk 466.5781 ❑ Lodi 3f83fi21 ❑ Menten Services E❑Traanty 8,w.,11116 <br /> P. <br /> j —--Applicant- Return all copies to: En•nronmerrol Hselth Permit/Services IfD1 E.Hazelton Ave., P.O. Boa 1008, Stk.,U 98201 <br /> , > FEEgMOUNT DUE AMOUNT REMITTED GSH RECENED BY DATE Pe tmer"O. <br /> (NEO <br /> • [M ISN la[V.la/aSi 1/C C 1't I� �—I y -'�T g��O~ <br /> a EX 1L� T'l r <br />