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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> n C� 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone(209)466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This applic.r..is <br /> male in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> — Local Health District. 1 1 �1/�_ <br /> Job Address ��( �/ Y�/sr_1A u�(;,L_RCL City"j4 Lot Size PM <br /> ` Owner's Name Address So �Lam- Phone <br /> Contract or4f __ YAC Address 19/9 f�n�License No13� 6ylkhoba <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR W OTHER ❑ <br /> eas DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> ❑IMuatrial ❑Open Bottom ❑Manteca Die.of Wel Excavation Dia.of Wen Casingnes <br /> Domeatic/Private ClGravel Pack ❑Trac Type of Cosi <br /> � Y ro rg Specification; <br /> n Public in other n(Det. Depth or Grout Seal Type of Gond <br /> I I Irrigation —Approx.Deptthh /III Eastern Suda Seal Installed bq_ _ <br /> Repair Work Done Type of Pump —ea H.P. — State Work Done <br /> Well Destruction ❑ Well DiameterSealing Material Itop 501 <br /> Depth Filler Material(Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I7 REPAIR/ADDITION(I DESTRUCTION I l IN.sePlic system permitted if public sewer is <br /> available within 200 fent.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sad to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo.Compartments s <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> s. Distance to nearest Walt Foundation Property Line <br /> LEACHING LINE ❑ No.A Length of tinea Total length/size <br /> FILTER BED ❑ Distance to beamed: Well____ Foundation Property Line l} <br /> SEEPAGE PITS I I Depth —Size 7lumber <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS -..❑ <br /> I hereby cartily that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and S <br /> rules and regulations of the San Joaquin Local Health DRArict. <br /> Home owner or licensed agent's sgnatum certifies the following:"I codify,that in the performance of the work for which this Permit is issued,1 shall not <br /> employ any parson in such manner as to become subject to workman's compensafl n laws of California."Contractor's hiring or sub­centracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persom subject to workman's compense- <br /> lion laws of California." /J <br /> The PI mu all for all required'd¢action Compl drawing on reverse side. <br /> Signed _Title: Pf Pp Data: <br /> .s nFP13.DEPARTMENT USE ONLY g <br /> APPlication Accepted byData ( Area <br /> Pit or Grout Inspection by v Data Final Inspection by Data <br /> Additional Comments: <br /> ❑Six 466-6781 ❑Lodi 369-3621 ❑Maintain BM-7104 ❑Tnry 835633M <br /> Applicant-Return all copies to:Environmental Health Permit/Services 1BOt E.Hazelton Ave.,P.O.Box 2(109,Stk.,CA SEMI <br /> INfO AMOUNT DUE AMOUNT REMITTED LASH RECEIVED BY DATEEY p PERMITT.rNO. <br /> 01 law.11.ti <br /> N <br /> In <br />