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`}-- APPLICATION FOR PERMIT -2- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELiON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 / <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ` OF <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described.This application is <br /> made in atch compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/Dump and the Rules and Regulations of the Sen Joaquin <br /> Local Health District, <br /> Job Address a/ I L G C i' / A <br /> C'n' r GL Lot Size J IO .Y�!j0 PM <br /> Owner's Name A p L!�r{ �u Y <br /> �Addres4 �� 7 �� .S' ��....�pL .C/aL Lar.. <br /> Phone <br /> Contractor 1 !{ <br /> Address� ,Z�,nt C. <br /> TYPE OF ELL/PUMP: NEW WELLp License No. Phone <br /> PUMP INSTALLATION p WELL REPLACEMENT ❑ pESTRU I(UN !7 / <br /> DISTANCE TO NEARSYSTEM REPAIR U OTHER <br /> SEPTIC TANK SEWER LINES <br /> F DATION DISPOSAL FLO. E <br /> "'---------. AGRICULTUR kER <br /> INTENDED USE TYPE OF L WELL PITS/SUMPS _ <br /> O Industrial AREA CONSTRUCTfON SPECIFICATIONS <br /> .Ls onom " AREA <br /> Dia.of WaU Excavation <br /> Ci Domestics e ❑Grave(Pack ------_ Dia.of Well Casing <br /> FI Pub ( OtherT»of Casing Specifications — <br /> 1 1 Irrgaticn fl Delta Depth of Grout Seal <br /> _. astern Depth !I Eassern "—'------ TYDa of Grout <br /> U Type at Pur <br /> Repair Work Done Seal Installed by <br /> r H,P. <br /> Well Destruction is Wen Diameter to Work Done <br /> --- Sealing Material(top 50') <br /> Depth Faker Material laelow..S0,1 —---- <br /> TYPE pf SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ <br /> ADDITION DESTRUCTION I I IN septic system permitted if public sewer is <br /> Installation will serve: Residence, available within 200 feet.l <br /> Number of li 'n - Commercial— Other <br /> yr g units: Number of bedrooms <br /> Character W 5011 to a depth of 3 feet: <br /> SEPTIC TANk, O Type/Mfg T Water table depth- <br /> PKG.TREATMENT PLT.Ll Capacity, U v Na CompaAments <br /> Distance to nearest; Wall (() Method of Disposal <br /> Foundation_� Property Lina _ <br /> LEACHING LINE Ll No,&Length of lines <br /> FILTER SED L-1 Distance to — Total length/size, <br /> nearest" Wei I° Foundation <br /> ^�) Property Ling <br /> SEEPAGE PITS Depth _ <br /> Size <br /> SUMPS eDtn __..._ <br /> Distance to nearest: — Number -` <br /> DISPOSAL PONDS i:� Weil Foundation <br /> Property Line__— <br /> t hereby cerri}y that <br /> I have prepared this application and that the work will <br /> be rules and regulations of the San Joaquin Local Health Oistrict. done in accords <br /> Home ownar of licensed agent's signafura certifies the follows ^�with San Joaquin county ordinances,state laws,and <br /> employ any person in such manner as to b ork.,I 'srtify that in the performance of the work for <br /> certifies the followin become wbieCi to workman's compensation laws ofhich this permit is tr - 1 shell not <br /> tion laws of Ca:ifor a.%I certify that in the pertorman�e of the work for which this California."CdlitI h.,,e ploy ars hiring of subconh <br /> permit is issued,1 shall employ <br /> acting ssgnawre <br /> Thi,applic&,must D Y Derswts Su <br /> to workman's cornpansa. <br /> WII o,all required inspections.Complete drawing on reverse side. <br /> Signed X r r <br /> ---- Date:. _. <br /> FOR OEPARTMENT USE ONLY <br /> Application Accgptod by X57 <br /> Pit or Grout Inspects -- Date Area �J <br /> Oat@ Finals <br /> Additional Com Inspection by Date <br /> Comments- <br /> ❑Stk 466-678'. ❑Lodi 369-3621 <br /> Applicant•Return an copies to:EnviManteca am-7104. <br /> ro�no""Heal ❑Tracy IEiS-6385 <br /> th Pem+it/Satyiepa 1601 E.Hazehon Ave.,P.O.Box 2009 <br /> Stk.,CA 95201 <br /> F.E AMOUNT DUE <br /> INTO AMOUNT RExtITTED CK <br /> M14M retv7•an1. t-� H RECEIVED BY DATE <br /> 1� �O PERM17N0. <br />