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�f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HA7.ELTON AVE., STOCKTON, CA <br /> Telephone (209) 486-6r 31 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> This 000606ftn is <br /> Application n hereby made to the San In.-qutn Local Health District for <br /> a peon In construct and/d pang the work Ilind Regulations deet Of the SanJb�rinn <br /> nude in corvltance with Sar Joaquin County Ordtnant.e No.549 for sewage a No. 1852 to tMeN/pMrP and the Runts and <br /> Local Health District. //.' <br /> C �� <br /> Z//�_4 � City "4lot SIE 95 Y <br /> Job Address � Y__-�-- ---� <br /> Phone <br /> Owners Name -.. <br /> Contrac;a -_ _ e6 / • icetese No. <br /> i <br /> t YPE OF WELL/PUMP NEW WELL (] WELL REPLACEMENT Cl DESTRUCTION D <br /> PUMP INS'.ALLATION O SYSTEM REPAIR U OTHER O <br /> t DISTANCE TO NEAREST SEPTIC TANK SEWER LINES --,— DISPOSAL FLO• PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITSISUMPS <br /> INTENDED()SE TYPE OF WELL <br /> PROBLEM ARIA CONSTRUCTION SPECIFICATIONS <br /> (7 Irndtntriel _-- L) Open-Bottom U Mott" Dim.of WON incitation - OIs.01 WON Camp <br /> O Domastic/Private (-I Gravel Pack O Tiny Type of Caeinq `- <br /> rl Public I Ulhvr Il Daly Depth of Grout Scat _ Type of Grout V <br /> I I ir,Vetion ----Approa. Depth I I intern Suttsoli Seal Inateasd by <br /> Repair Work Done l 1 Type of Pump H.P. State Werk Don <br /> Weal Destruction l 1 Wer Dunwor SOWV Material Itop 9n•) ~ <br /> Dept', _ Fire Material IBebw 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAI N/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> evWble vtrlthin 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: NUWAW of <br /> Character of soil to a depth of J het: Water Iabb depth <br /> QA <br /> SEPTIC TANK [l Type/Mfg Comparut+ents <br /> PKG. TREATMENT rLT I Methr�01 Disposal <br /> Distance to neeeet' Wee Foundation Property Lins g i <br /> LEACHING LINE T l 1 No. 5 Length of Enae Total Nrtalh/eie <br /> Fit TER BED l I Dtatance to mercer: WMZ_ Farnda;lon Clete <br /> i <br /> SEEPAGE PITS I i Depth --1 _Sire <br /> SUMPS l I Distance to nearest: Well <br /> Farndstion,��'S%aProPMY Lin <br /> DISPOSAL PONOS I) <br /> 1 hereby cetifY that I have prepared this application and that tis Wolk vine W done in accordance with San Joegtrin co4ry oris,state Win,and <br /> nAn and regulations of the San Joaquin Local Health Dktrkt. <br /> Honer owner or licensed agent's signature ca Hiles the foeovAng-•9 cw y that In the performance of the work for vdtioh this permit is issued.1 d"N not <br /> turs <br /> env"env person n such manners to become sul*0 to workme n•s compensation Pews of California."Contractor's hirft or sub cont►eo-ac '"We're" <br /> certifies the following "I cemty that n the Wornwicis of the work for which this permit Is issued,I ahaN etmpby Mons SiMaet fo workman <br /> cemtparra- <br /> tion laws of California " <br /> The applicant net call for aftionowed ins tion. Complete drawing on revers <br /> e side. <br /> Sip+sd Y — <br /> 1►� This: .l'f?�/\ _ Dow: <br /> .._�---- <br /> FOR DEPARTMENT USE ONLY <br /> Appliestbn Accepted by <br /> �� f Data Anes <br /> p• <br /> Pk or Grout Inspection by Date Final Inspection DY Oats <br /> Additional Comments _ <br /> ]Stk a866781 0 Lodi M9-3621 O Manteca M71.04 O Tracy 4354= <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1001 E. Her~Ave., P.O. Boa 2009, Stk.,CA 95201 <br /> FEE <br /> AMOUNT AMOUNTIIEMtTTEO CASH RCCEIVED eY DATE PENMIT'NO.INFO <br /> 1134 tete • � 7 �.� <br />