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i <br /> e <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ! <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE iSSUED <br /> (Complete in Triplicate) licorice Is .� <br /> Application is hereby made to the San Joamdn Local Health District for a permit to construct and:ur install the work herein described.This app I <br /> made in compliancy with San Joaquin County Ordinance No.549 far sewage ar No. 1862 for well/pump and the Rules and Regulations of the Joagom <br /> x. 11 <br /> Local Health District..�1 Q/L! A <br /> ✓/ L1 24 / Q'7Ly//—�'Z, — Cry Lot Sim <br /> Job Address - <br /> / ,P� Phone <br /> xxx F <br /> T' Atldress _.—i O <br /> Owner's Name <br /> dress <br /> TYPE <br /> rise Nqlabor. <br /> E OF - <br /> TYPE OF WE L / NEW LL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> SYS <br /> PUMP INSTALlAT10N E3 SYSTEM REPAIR ❑ OTHER ❑DISPOSAL FLD.__ PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES PITS/SUMPS _. <br /> FOUNDATION AGRICULTURE WELL _— OTHER WELL �s <br /> NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing \ §� <br /> V 3 <br /> Industrial [:1 Open Bottom ❑ Manteca Oie.of Well Excavation <br /> [I Industrial (. <br /> ' Type of Casing \ <br /> Cl Domestic/Private ❑Gravel Pack ❑Tracy Depth of Grout Seal Type of Grout <br /> i M Public ❑Other n Delta _ <br /> I I Irrigation —Approx. Depth I I Eastern Surface Saul Installed by <br /> - H P __ State Work Dotte� <br /> Repair Work Done LlType of Pump Seating Material(top 50'1 - <br /> I Well Destruction ❑ Well Diameter <br /> y Depth Filler Material IBelo '1 <br /> L or <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIfl/ADDITION DESTRUCTION I 1 2vsilab�e within 200 feet.zlza It pubhe sewer is <br /> Instigation will serve: Residence r Commerrial_ Other <br /> L Number of living unlit:__t.__ Number of bedr s Water table depth <br /> Character of soil Io a depth of 7 feet:_ Capacity No.Compartrrlems <br /> SEPTIC TANK .❑ Type/Mfg Method of Dlaposal e <br /> PKG.TREATMENT PLT.❑ Foundation Property Line <br /> - ( Distance to nearest: Welt <br /> i Total length/size _ <br /> LEACHING LINE No.8 Length o1 lines -� �1 <br /> ` <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation�as�— Property Line�— <br /> L <br /> SEEPAGE PITSUMa DI Distance to nearest: W211/epth �0— Foundation.. Property Line 9: <br /> ISPOSAL PONDS ❑ Joaquin work II be doaccordance with San Joeq <br /> oyd s state lilvint.and <br /> I hereby earthly that I have prepared this application and that the <br /> t rules and regulations of the San Joaquin Local Heal:h District. <br /> Horten owner or licensed agent's signature certifies the following:"I certify that in the performance of the wort for which this permit is issued,I ths.t not <br /> employ any person in such manner as to bocorrle subject to workman's compensation laws of California.,,Contrauofa a subj c sub-cokman'sg mpenute v. <br /> ' canities the)allowing:"1 certify that in the performance of the work for which this.—emit Is issued.I shall employ Penins subject to workman's compo^u" <br /> not laws of California:' $ <br /> The aPplicent"ma5Lea1 r all rggahpd mapeeup D6mdete hewing an remorse slily. <br /> I Jam. L/ 1 Date: "a <br /> .� [�I I • ' .6�n�a Title: <br /> Signed%- <br /> FOR DEPARTMENT USE ONLY I <br /> f /"11n�I / _ <br /> Date Aro _rt i <br /> Application Accepted til' g <br /> pit or Grnut Inspection by <br /> Data <br /> Final Inspection b Dat ,,. <br /> ` j Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 873-7104 ❑Tracy 615-6'!85 <br /> P.O. Box 2(10'1. Stk., CA 115201 <br /> Applicant � Return all copies to: Environmental Health Pyrmit/Sarvicea 1601 E. Hazelton Ave.. 4� <br /> CK o I1E it I Qict <br /> eY DATE PERM"'ND. ¢f <br /> IFEE NFO AMOUNT 0-M AMOUNT REMITTED OASN n <br /> . FH 424 IAA I r n el F <br />