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APPLICATION FOR PERMIT <br />` -ISAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL T CON AVE., STOCKTON, CA <br />Telephone (205) 456-6761 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplic u) <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wok herein descried. This dun is <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 18V for wel/pump and the Rubs w 1 �� <br />Local Health District. r� jj - 1 p <br />Job Address - , yl I ! 17_-. <br />U'.j Cnty Lot S"ae _. ��.;��_^`Lt _�i_W�t>M <br />i� <br />1i �". a �' "" <br />Owner's Name _ <br />^ A+ddreas I •5�I''f Phrase <br />Contractor <br />SAM Address 154_2-_M License No. Phmw <br />TYPE OF WtEUJPUMP: NEIN WELL O WELL REPLACEMENT 0 DESTRUCTM 0 <br />00 <br />tJ-✓'"'�r <br />PUMP INSTALLATION © SYSTEM REPAIR O OTHER <br />DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES DISPOSAL FLD. MOP. LINE ,.. <br />FOUNDATM AGRICULTURE WELL OTHER WELL Prm/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />C Industrial <br />C Open Bottom C Manteos Die. of Wall Excervation Dia. of lrm caft <br />C Domesticiprivate <br />' Graver Pads C Tracy Type of Casing Specifications <br />C Public <br />Other C Dens Depth of Grout Saal Type of Grout <br />C Irrigation <br />___Approx. Depth C Eastern Surface Seal installed by <br />Repair Work Done <br />C Type of Pump H.P. State Work <br />Well Destruction <br />C Wait Diamater Sung Material (top W1 <br />Depth Fir Matarial (Below 5W) <br />TYPE OF SEPTIC WORK; NEW INSTALLATIO REPAIRIADDITION 0 DESTRUCTION No sepsis system pdrrrnitted If wAk sewer is <br />�.✓' available within �Ob feet.) <br />Installation waif serve: Reidance ./�,. L:orrur4erc�1 _ Other <br />Number of living <br />whs: Number tri bedroams --^ � <br />Character of soil to a depth of 3 feet: Water table dearth <br />SEPTIC TANKTypo/mig <br />Capacity C.1 No. CompartmertIs <br />PKG, TREATMENT PLT. C t Method of Dim <br />to nearest: We" . _ Foundation Property Line <br />LEACHING LINE <br />,�,/.-Distance <br />> No. $ Length of linesTorp)I langth/size <br />FILTER BED <br />C Distance to nearest: well Foundation _ ;JY Property Line <br />SEEPAGE PITS <br />C Depth Sita N1116W CR <br />SUMPS <br />Distance to rwsrest: Weq F� Property LHtO .,..� <br />DISPOSAL PONDS D � <br />I hereby certify that 1 have prepared this application and that the work will be dam in accordance with San Joaquin county ordinances, stags laws, and <br />rules and regulations of the San Joaquin Local Health District. <br />Horne owner or licensed agents signature rimes the fohowhW "I certify that in the performance of the work for which Oils pemrit is is kwd, I shall not <br />wnptoy any person in such manner as to become subject to workman's eornponsation lews of California." Contractor's hiring or sub-contractdng vignature <br />cwtifies the following: "I certify that in the pstfortnance of the work for which this pwn* is iseusad. 1 shag employ persons subject to workmen's mmwvm_'' <br />tion laws of California." <br />The appdica t call inspections. Complete drawing on reverse side. <br />Signed Title. jjfi /` Date: v' <br />FOR DEPARTMENT USE ONLY <br />Application A by .� r 9 V,�it,..✓' pate ''� j�j Area <br />Pit or Grout Inspection b=rte i Date Firs inspection by Daekei�r <br />• • • •"liG1l[�1f2s'lr«slt-.iEi.".�Qr?r:1i tai I< "!Wff� LiiilsTt[:?!t1IE.11111 I diWAI .4 W:k'MAl IFA <br />r �i �•Z4 V. tl s e) <br />aN tm <br />INNFFO <br />AMOUNT DUE <br />CASH <br />RECENED BY <br />oATE P£Rmtr No. <br />00 <br />tJ-✓'"'�r <br />EAMOUNT�REEMrrrEo <br />V <br />j <br />