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�--� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVF., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> App6r.athon rs helehv made to the San,Inantrin Local Health District lot a r"rmd to construct an1!or install vie work herein described This eppicstion Is <br /> made In Complatn%o with San.loaqutn County OrAtnance No. 549 for sewage or No 1 Wit for wen/pump and the Rules and Repulauons of the San J""equen <br /> i <br /> local Health Dtslncl <br /> 1n►r Address /�T 7t'`�� _�t�✓YA.:L a`-aL.._w__.._,_.�- City_5�. ti�erl�9___ 101 Site..L" �— PM [� <br /> Ownm <br /> ers Nae Addruaa Ph. — <br /> r <br /> 1 <br /> Contractor _s/� � Address_ � —�_License No..ZC'�L�PIIOIu 68.x' <br /> TYPE OF WELL/PUMP- NEW WELL I WELL REPLACEMENT I i DESTRUCTION (I <br /> PUMP INSTALLATION L1 SYSTEM REPAIR (l OTHER II <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 /> U Industrial C3 Open Bottom 0 Manteca Dia. of Weft Excavation _ Dia. of Well Casing <br /> I 1 Domestic/Private U Gravel Pack ❑ Tracy Type of Casing Spectfications <br /> 1-' Public 1 1 Other Fl Delta Depth of Grout Seal _— Type of Grout <br /> I I Inigatton __ Apfxo•. Depth I I Eastern Surface Sedl Installed by — <br /> Repair Work Done II Type of Pump _ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 <br /> Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION! REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted of public sewer is <br /> available within 200 feet.I <br /> Installation will serva: Residence Commercial_ Other <br /> Number of I vtng units: _L— Number o edrooms — <br /> r n <br /> Character of soil to a depth of 3 feet - �---__Water table depth ry) <br /> SEPTIC TANK (,/Type g t No. Compartments 1— <br /> /Mf !/Yf� - / -�Capacity�...�SQ-- <br /> � Method of Disposal <br /> f KG. TREATMENT PLT. U � , . <br /> Distance to nearest: Wetl �_.FolxMaflerl — Property Line e� _. <br /> LEACHING LINE Cl,-114o. &Length of linea �Y-o�1�Mrgth/'i'a_fZ <br /> FILTER BED 0 Distance to nearest: Foundation Property Line <br /> G <br /> SEEPAGE PITS t j/Depth -- <br /> SUMPS L1 Distance to nearest: Wen � It Foundation—JQ Prop"Line- <br /> DISPOSAL PONDS Cl <br /> +� he work will be done in ace«dance with San Joaquin county ordinances. state laws, and <br /> I hereby certify that I have prepared this application and that t <br /> tinea and re3ulations of the San Joaquin Local Hea th Oiklrict. <br /> HOny owner« aparttI signature certifies ti.,:ioaowing:"I certify that In the performance of the work f«which this permit is issued.I shall not <br /> a Wow any parson auch merrier p'o become s A*W to workmen's compensation laws of Cali Orme."Contractoes hiring«sutrcontracling signature <br /> Cafdflee the f0ppwing:•'I cartify that In the performance of the work for which this permit is issued.I shelf OmPIOY persons subfect to-0rk—s Con4--- <br /> tion laws of Caiifornia." <br /> The applicant m�usttcall for aNtrans. Complete drawing on reverse side. <br /> Signed X L�C..C�.� Title: . e.* Date: <br /> FOR DEPARTMENT USE ONLY � <br /> Application Accept/d by _ Date �7-- ArM --r 2—e--� <br /> [incl Inspection by <br /> Grout Inspection by <br /> VVAdditional!ComirA ts: <br /> D Stk 466.6781 O Lodi 369.3621 O Manteca 823-7104". O Tracy 836-s ib- <br /> Applicant- Return anC0001C000111w <br /> to: Erkommental Health Perrttit/Services 1001 E. HazeR«+Ave., P.O. Box 3000,11111116.CA 9fi20t <br /> FEEAMOUNT DUE AMOLINT REMITTED RECENED SY OATE PERMIT NO. <br /> INFO n CASH . <br /> . EN qN IRlV treat •/ V..► -71 <br /> rM r�M <br /> J <br /> ; r�, . <br />