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IIA <br /> APPLICATION FOR PERMITF , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 52091 4664M <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> (Complete in Tripikatel <br /> Application Isyr <br /> heroby masa to the San Joaquin Local Health District for a permit to construct and/or inataN the vrork hatskt tiaaetIto <br /> d.This app6Cafbn to 7 <br /> i made in c-"'PNance whh$en Joaquin County Ordinance No.549 for sewage or(1o.IBM for waR/pump and the Haal mid <br /> 4 Lout hsait'i District. lAapttfations d ow San.101111011 <br /> T Job Address <br /> p / Chy t3f1 Lot SimPM " r <br /> Owneds ryame S/_�{^ n L f r <br /> { Address Phona Yk <br /> 511 <br /> Contracior —Address r License No.�_ phorte <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ •f <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t; <br /> ' DISTi3NCE TO NEAREST: SEPTIC TANK SEWER LINES DiSP05AL FLD, PROP.L1kf <br /> rFOUNDATION <br /> OTHER WELL PETS/SUMPS AGRICULTURE WELL <br /> SNTENDEIA USE TYPE OF WELL PROBLEM AREA <br /> CONSTRUCTION SPECIFICATIONS '�3`•;� <br /> ❑industrial ❑Open Bottom ❑Manteca Dia.of WallE�tcavation Dia.of Welt Cesitg <br /> ❑Domestic/Private CJ Gravel Peck ❑Tracy Type of Casin SpadpK G, <br /> ;a <br /> r� � CJ Pudic ❑Other ❑Delta Depth of Grout Seal Typo of Craut <br /> ]irrigation __Jlpprox,Depth ❑Eastern Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done <br /> WOR Destruction ❑ Wolf Diameter Searing Material flop Sal <br /> Depth F1br iltaterial fBeknv 50') <br /> TYPE[Sr SEPTIC WORK: NEW INSTALLATION FT RE?AIg/ADDITION❑ DESTRUCTION Cl iNo septic system pemdttad H <br /> IN <br /> avalabb within 200 few.1 <br /> installation will serve. Residence_ Commercial_ Other �� •: �, <br /> 0.. Number of riving unitsNumber of bedrooms ' <br /> 7+_ Character of so"to a depth of 3 leets <br /> r_.,rt�fa�f tL Mater table depth <br /> SEPTIC TANK ❑ Type/Mfg ,i. <br /> -F CapatitY—I1LLLL L No. Compartriunts <br /> PKG.TREATMENT PLT.❑ Method of D <br /> / 1 <br /> Distance to nearest; <br /> _� Well Foundatlon. a Property Line <br /> :. a i <br /> LEACHING LINE No.✓4 L th of lines -a hot <br /> Total length/size.c <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PiTS 011,Depth <br /> p •—���51te__ �-3 Number <br /> • SUMPS ❑ Distance to nearest: Wali_ 1�r� Foundation� Property Lina <br /> DISMSAL PONDS ❑ .^! <br /> r hereby certify that I have preparod this application and that the work will be done in ac%mdance with San Joaquin County ordinances,state lows,and <br /> rubs and reguiatians of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for wh;ch this pemtit is isstrad,I shsq not <br /> employ any person h,such manner as to become sub' t to workman's compensation ptnaatlon laws of California."Crntra,.,-. <br /> ttr's hiring or sub-contracting sigrtatttra � <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 cantpartsa <br /> tioq haws of of California." <br /> 4 .. <br /> The applicant must call for all required inspections.Complete drawing on reverseside. <br /> }.. <br /> v Signed viat Iitis: p'r t f <br /> 47/ -7 <br /> Date: <br /> ` FOR bEPARTMENT USE ONLY <br /> 640 <br /> �J - <br /> Application Accepted by Ares Q j <br /> Pit a Grout Inspection L♦ �A Date -l`8?— Final Irupection by One ,� ,F7 <br /> Additional Comments: - <br /> ❑Stk 4664791 ❑Lodi 389 OfMantsics 823-1r104 ❑Tracy <br /> Applicant-Return as copies to:Emikonmental Health Permit/Services 1801 E. Hatekon Ave., P.O. Box 2009,Stk.,CA 96201 <br /> F. tNW AFAOUH7 CIA AMDUNT REAAtTTED CASH RECEIVED 9y DATE PERMtT'NO. <br /> ' ttr rase <br />