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APPLICATION FOR PERMIT 1?1_ht <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate), <br /> 14 C. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County.Ordinance No.5.49 for sewage or No. 1862 for well/pump and the Rules-and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Si.,e:S PM <br /> Owner's Namerr F.Lt -Address Phone <br /> li-4 s <br /> Contractor Address F&T V/df License No PhoneK3171 <br /> TYPE OF WELL/PUMP: 60—W— - <br /> NEAVWELL Ll WELL REfLtKEMENT E DESTRUCTION C <br /> PUMP INSTALLATION 1-1 SYSTEM REPAIR'EJ OIUEFO��� <br /> PISTAN,CE TO NEAREST: SEPTIC TANK SEWER LINES DISPS�_ I _— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS <br /> INTINDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS <br /> Indus'trial .0 Open Bottom 0 Mante Dia. of Well Excavation Dia. of Well Casing <br /> D.A I sticl Private 0 Gravel Pacd racy_ Type of Casing Spkifications <br /> El Public 0 Other ❑ Delta ' Depth of Grout Seal fl Type of Grout <br /> LJ Irrigation prox. Depth El Eastern Surface Seal Installed by <br /> Repair korL_kDon Type of Pump H.P, State Work Done <br /> Well Destruction , 0 Well Diameter Scaling Material (top 50') t. <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION 11 DESTRUCTION <br /> .KiNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence I Commercial— Other <br /> Number of living units- Number-�ofgbedrooms <br /> Character of soil to a depth of feet: Water table depth -n <br /> SEPTIC ANK Type/Mfg <br /> Capaci'it No. Compartments <br /> PKG. TREATMENT PLT. L1 Method of Disposal <br /> j <br /> Distance to nearest: Well Fou Afio—n Property Line <br /> LEACHING LINE 0 Nol.& Length of'lirfe*S;114__N1 I T al length/size <br /> *IFILTER 6D <br /> Dislance tonearest: Well Eoundatiop Prope <br /> rty Line <br /> 7MEEPAGt PITS ElDeAth T -Size Number <br /> I — <br /> eumps Ll. Distance to nearest:. Well ?oundation Property Line <br /> t'DISPOSAL PONDS 0 <br /> -1 hereby certify that I have prepartd this application and that the work will1be done in accordaAce with San Joaquin'county ordinances, state laws, and <br /> crules and regulations of the San Joaquin Local Health District. <br /> employ <br /> owner or licensed agent's signature certifies the following: "I cer_tijy hat in the performance of the work for which this ermit is issued, I shall not <br /> /employ any person in such manner t�s�tobec�on�Wrubj�c t_o­w.`or_k1"­ <br /> man s comp9nggtib7ni'a 'California." Contractor's hiring or,sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws,of California." <br /> ja I <br /> The applicant drawing on averse side. <br /> �rall required in�sion8,�Comp <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dater Ca <br /> Area <br /> Pit or Gr ut Inspectio Date Final Inspection by_VC, le-4 Date 2JAV <br /> Addition! Comments: <br /> 0 Stk 6781 11 Lodi 369-3621 0 Manteca 923-7104 13 Tracy 835-6385 - <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952011 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH— .--RECEfVEDE6Y--_-� RMIT'NO. <br /> + EH 13-24 IREV.'I,H 50 O Vfkn <br /> EH 14-26 IA-o ,--Zl ux- <br />