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APPLICATION FOR PERMIT
<br />,0
<br />SAN JOAQUIN -LOCAL HEALTH DISTRICT
<br />1601 E. HAZEL T ON AVE., STOCKTON, CA "Ic4f
<br />Telephone: (209) 466 -Ml
<br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />(Complete in Triplicate)
<br />Application is hereby made to the San Joaquin Local Health Distract 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. 549 for sewage or No, 1 S for well/purnp and the Rules and Rogui,ations of the San Jaagtin
<br />Local Health District. y
<br />Actjob Address City Lot Size._. �r�_._ PM
<br />Owner's Name _�li i�? --_ .0 ddres Yt r�✓ - Phone
<br />.4 _
<br />Contractor Address ..4 a' 1 `+�,,.,i License No.
<br />TYPE OF WELLIPUMP: NEW WELL rl WELL REPLACEMENT 0 DESTRUCTION 0 �
<br />..�Pt��,tr-INSTAt::iAi'CON•.i�.,,...,.�..,,...,...-,...-.=.SYS7£hl1�iEPAiR-Cis'_..._.......„.,.„.,..,,�LS7HE#���,»..<,....., � r�
<br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN£
<br />1 FOUNDATION AGRICULTURE WELL OTHER WELL _ PCT'S/SUMPS\ -__
<br />t, INTENDED USE TYPE OF` WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br />i 7 industrial Cl Open Bottom M Manteca Dia. of Well Excavation Dia. of +Nall Casing _
<br />DomesbclPrivate C Gravel Pack Tracy Type of Casing._.._. __.. .,_.._ _ Specifications
<br />Public
<br />i:: Other i,
<br />i l Delta Depth of Grout Seat Type of Grout
<br />.' _.
<br />irrigation
<br />_..,,,.,.-_Apprscx. Depth
<br />.,0 Eastern Surface Seal Installed by...._____.._..,
<br />!”
<br />,
<br />Repair 'Work Done 0
<br />Type of P� _
<br />a une
<br />� H P.$W�o'r..k"D
<br />Well Destruction
<br />fState
<br />�liametr
<br />r
<br />2Yial 2Fd r Material ekn501
<br />e
<br />TYPE OF SEPTIC WORK: NEW INSTALLATION;Ci-REPAIR+Ab TION DESTRUCTION r1 {No;septic system permitted if public, sewer is i
<br />'r, ew. `• s..,..-aWilabie within 200 fetiA
<br />all serve:. � r'.'1 �'.i ,rz►P /tri+
<br />instaka icn ve:. Rtrsidex.oe _ Commercial
<br />�•��Ai I
<br />Number of living units: _ _ fi rnm of bedrooms ?r A t
<br />Character of sail to a depth .of 3 feat: __ ""' "" Wat9t;tahle depth .__..�
<br />t e
<br />SEPTIC TANK T '"'�` ��'
<br />Type/Mfg 14, ..� . Capacity tom" No. Compartments
<br />w PICC>> IfIEAThAI l•7T PLT'. 'J I a t t _ s % "'`3 Method of 17i sal "
<br />Distance .to nearest: , Well "�W= P F�und bon ProplM lire `f
<br />S �,, ,�` _••��.y„y= a /
<br />LEACHING LINE L.: No. $ Len of lines Total /size
<br />FILTER l3l O % D scenes to r{3st: ,, ,,,,Wtdl.. ,d FtaGndaU'os.a� ._ Property Line,_X y W lV p a
<br />l �i ' . `•
<br />SEEPAGE PITS S C D size Number ..__. � , ' "
<br />SUMPS rstnce to nearest. well _. Foundstion Property Line( ?
<br />DISPOSAL PONDS
<br />I hereby certify that I have prepared this application and that the work will4a done in accoidin'ce with San Joaquin county ordinances, state laws, and
<br />ruffles and regulations of the San Joaquin Local Health District.
<br />Home owner w licensed agent's signature cartiffies the folowing. "I certify that in the pe domsance of the work for which this permit is Issued, f shag rust
<br />employ any person in such manner as -to become subiaci to workman's compensation,laws of. Califorrya.' ��ontwr tor's hiring of sub.contracting signature
<br />certifies the following, "I cartity that in the performance of the work for which this permit is issued, I shalt employ persons subiect to workman's compensa-
<br />tion :aws of Catoomia", ,!
<br />The appfi nt mu all fora qLiir spectio s. Complete drawing or reverse We,
<br />Signed )i_. T ttlet: __ ��?Yt k"✓ "; t Date: iG J'
<br />s
<br />FOR DEPARTMENT USE ONLY
<br />Dia .
<br />Application Accepted by Area
<br />_ -f— .=L--- _.
<br />',c
<br />Pito rout Inspection by Final Inspection by Date _
<br />Adfd t al C menta:
<br />Sill, awg#j8-1 0 Lodi -369=3E2t'_..,"'"CJ":+ila`riiwc`�' 128-iiiY/ :� Tri .836,,63%
<br />Applicant - Return all copies to: Environmental Health PertnitfServioes 1601 E. Hareiton Aye_ P,O. fiat 2009, Stk., CA 96X1
<br />1i l
<br />r; 3
<br />EH 53.2: iAEV, : re s�
<br />EH 4:26 ,
<br />FEE
<br />1 INFO)
<br />AMOUNT DUE
<br />AMOUNT REMITTED
<br />RECEIVED BY DATE PERMIT NO.
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