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APPLICATION FOR PERMIT <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1001 E. HAZELTON AVE., STOCKTON, CA <br /> T"01wo (200),86.0781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cof WIW in Tdpkm) <br /> AOYrearOn k Italaey reeds tp tlma Ban JoaquinWeb in Lood Hadden District for•Pann! to coretnut 8041110FInSW the work herein daao,ibad.This app&wdon M <br /> LOW Hoeft <br /> o I� 8M Joe" LOGO Ordinance No.6M for mm"rofr No.1K2 for weNooan <br /> /pp and the AWN d Regulations of dw San Joaquin <br /> Joe Ad*m Of �l /' / „e AJd .1 � /YdejALot Site PM <br /> omwe N.n1.��a D I4 SE L V 21 RA Add<... S <br /> SC Phos. <br /> Conlracwe Naar -Jv.A— Umw No. _ Phone <br /> TYPE OF WELUfzIJMP: NEW WELL O WELL REPLACEMENT C DESTRUCTION <br /> KW UMP INSTALLATION O SYSTEM REPAIR C <br /> OTHER O <br /> DISTANCE TO NEARM: SiPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL MOSLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O kxkwvw O open Bottom C Manteca 04.01 WON Excavation Dia. of Well Casing <br /> ❑Dortwtic/Prlwu O Gravel hack O Tracy Type of Caalnp Specifications <br /> O Public O Other O Dake Depth of Grout Sad Type of Grout <br /> ❑krigatim ---Approx. Depth C Eastern Surface Sed Installed by <br /> Repair Work Done O Type of Pump H.P. State Work I Done <br /> eav , <br /> We/Dsuction O Wall Diemew S"Wg Material 60'1 J&k`4-- <br /> Depth Filar Material IBdow 60'I (31 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION C DESTRUCTION 0 INo aseptic easter permitted If pubic ower is <br /> avON"within 200 fast.) <br /> Installation Will terve: Residence_ Corrrthercld_ Other <br /> Nmrnba of 6vinp unit Number of bedrooms <br /> Chw&Cter Of Boil so a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capachy No Compartments <br /> PKG. TREATMENT PLT.C Method of Domed <br /> Dkwancs to nearest: Wee Foundation Property Line <br /> LEACHING LINE O No. &Length of Baas Total length/size <br /> FILTER BED ❑ Distance to nearest: WON Foundation Property Line ,� \ <br /> SEEPAGE PITS C Depth Sia Number �J <br /> SUMPS ❑ Distance to nearest: Wee Foundation Property Lie <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or' , .agent's signature cert»its the following:"I certify that in the performance of the work for which this permit is iwud.I oW not <br /> employ any Person in such manner as to become subject to workman's comperwtion laws of California."Contractoes hiring or sub-contracting signature <br /> certifies the following:"I certify that in;he performance of the work for which this permit is Issued,1 efa8 employ Persona subject to wod~ls comperw- <br /> tion laws of CaWomis." <br /> The applicant must call for a8 required inspections. Complete drawing on reverse side. <br /> Signed X C AC.C. i]ti_o C CCo,,_ This: AC,o t- <br /> Data: <br /> FOR 0 ARTMENT USE ONLY <br /> Application Accepted by Area a 6 <br /> Pit or Grout Inspection by Date Final Inspection DSS-It -(Yl <br /> i <br /> Additional Comments: //7 l,i. eC-1 ..rj - <br /> ❑ Stk /66-6781 ❑ Lodi 30 3621 ❑ Manteca 823.7104 ❑Tracy <br /> Applicant. Return ae copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave., P.O. Boa 2005, Stk., CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> ED RECEIVED 0Y DATE PERMIT NO. <br /> . EM 13-24 IIIN 10/43, <br /> EM.251 o p �1p1 ��\ /►.i '1 �S 3 y <br />