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APPLICATION FOR PERMIT �u'v.�.=..•. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> Da 7 PIA Jn C'S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application's hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in ermpllence with San Joaquin County Ordinance No.50.9 for sewsge or No.1862 for well/pump and the Rules and Regulatiorn of the San Joaquin <br /> Local Health District. <br /> pJob Address ��� / -0'E r�� Ci�tlot Sizes?g's PM <br /> '.} Owner's Name ^CQay.�,r/csDKJ AddressTT /��/7 e14-'a4d7JS.T>�'f� Phone �r,���-,�_/�/�- d <br /> - Contractor �-+ -* Address-3� Y �'1/ ' License NaT1 _�i Phonal— <br /> TVPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION (] <br /> .,' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 15 Open Bottom ❑ Manteca Dia.of Well Excavation Du. Orwell Casing <br /> C3Domestic/Private ❑Gravel Pack _ C1 Tracy f Typo of Casing_ <br /> ❑ ,1 Specifications <br /> [3 PublicC Other Jello I Depth of Glol-t Seal - Type of Grout f� <br /> C Irrigation _Appro:.. OePth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type •: " ..P N.P._ ._ State Work Done O <br /> Well Destruction C Well Diameter I. Sealing Material Lop 501 <br /> ` Depth Filler Material Mallow 50'1 Jam; <br /> t <br /> TYPE OF SEPTIC V/ORK: NEW INSTALLATION ❑ RfPAIR/ADDITION DESTRUCTION ❑ ovailabpe whhine2W feetrred it public sewer is <br /> Installation will serve: Residence/lam Commercial_ Other — 1, <br /> Number of 1lying units:—/-- Number of Brooms Water table depth <br /> Character tif;seil to a depth of 3 feet: .!� cvl �/ No.Compartments <br /> :. SEPTIC TANK ❑ Tyae/Mfg f /�7 capacity�fld��q� <br /> PKG.'REATMENT PLT.❑ E Method o1 D�isp sya—I <br /> Distance to nearest: Well��Foundation_L_. Property Line JSL_ <br /> y <br /> LEACHING LINE No. 8 Length p Total IenBope ity 7 <br /> �t Pro Line— <br /> t <br /> FILTER BED ❑ Distance to newest: Well Fou �m <br /> '..t ,,,,,,/// e Number <br /> SEEPAGE,PITS yy Depth ZS Size�- <br /> SUMPS /❑• Distance to nearest. Well_ Foundation Property Line <br /> DISPOSAL PONDS ❑ t <br /> i hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances,state lawn,and <br /> rules and regulations of the San Joaquin Local Health District. rshall not <br /> Home owner or licensed agent's signature certifies the folluwing:"I certify that in the performance of the work for which this permit is issued, <br /> signature <br /> employ any person in such mantel as to become subject to workman's compensation laws of Califoshall amonotracto Contracng or tors <br /> act to workman's core the following."I certify that in the performance of the work for which this permit is issued, p y Per I <br /> _ tien laws of Caffornia:' <br /> The e,plica m e or /�=iirjjyns. Complete drawing on revers ride. <br /> Title:_ min Date: <br /> Signed X - <br /> ' FOR DEPARTMENT USE ONLY <br /> _ Late�. Area_ <br /> Application Accepted by <br /> j (PVV 1- `eta Final Inspection by_LP��(i+a.J:L-' Date <br /> rt r Grout Inspection by Nate <br /> l Additional Comments: <br /> ❑Stk 466-6781 ❑ Lodi 3643621 ❑ Manteca 823-7100 ❑Trary, 83546385 <br /> alth Permit/Services 1601 E. Hazelton Ave., P.O. Boz 200 Stk., CA 95201 <br /> Applicant-Return all copies to: Environmental He <br /> I CK RECEIVED BY GATE PERMIT N0. <br /> 1 E gMOUNT OUE AMOUNT REMITTED <br /> NF0 CASH <br /> I I <br /> [FE <br /> /3o/Frb 671T <br /> �J.op <br /> EH 1Lla <br />