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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTO 1► <br /> CSR u <br /> Telephone (2091 466-6781 v1, <br /> PERMIT EXPIRES 1 YEAR FROM DATE <br /> (Complete In Triplicate) <br /> Application is hereby math to the San Joaquin Local Health District for a permit to conseuct and FACt <br /> made in compliance with San Joaquin County Ordinal NO.549 for sewage or No. 1862 for we+t wrtraaa a Rules and ncL u(A, i f tho Sar uoaya.n <br /> Local Health Dallict. ��V 7M► V <br /> Jab AIXlrass City _ l n• Sim _- PM <br /> Owner's Name e ♦ _4�LT _ _._ Altus _Js1 dr.I.I_ .� sy� �,�-_ D 67 <br /> a t r(1L`e�M�`?' , (7_ hon°f'I <br /> Conlractp _ . . _ dress// V J �] _ _ License No •aV _ I <br /> TYPE OF WELL./PUMP r NEW WELL G W, LL RFPLA(',Eb1flIJT 7 DESTRUCTION 11 + <br /> PUMP INSTALLATION (J SYSTEM REPAIR it OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK - .. SEWS LINES _.,.._a�_.__ DISPOSAL PLO,____._ PROP. LINE�...L <br /> FOUNDATION — AGRIC LTUR ELL OTHER WELL PITSISUMPS k <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> G trwustial ❑ Open Bottom 0 Manu :Dia. of Well Excavation. Die, of Well Ctising <br /> O Domestic/Pllvaca Ll Grave(Pack D? TYPE of Cesin9 'SpeeMkatiom <br /> 1-1 Punkt, O Other 'r& Depth of Grout Sea! T <br /> Yee of.Grout <br /> I I Irrparlon ..___Approx, Depth i t Eastern Surfac eSeal Insulted by <br /> Repair Work Done (J Type of Pump — k: ._ Scale Work Done _ <br /> Well Destruction ll Well Diameter _ . S a!ing Materiel(top Tid'I <br /> Depth_ or Mabotal(Below So'I .� <br /> TYPE Of SEPTIC WORK: NEW INSIALLATION REPAIR/ADDITION i I DESTRUCTION 1 : INa a,Ftic system permiltnd if public fewer is <br /> available within 2110 1oet.l <br /> Instadaikat wig servo: Residence __ Commercial Other _.. _. _ <br /> Number of living units: Number of bedrooms <br /> Character of sal to a depth of 3lout: Water table depth <br /> SEPTIC TANK 111Type/Mfg %iA Cep9city k_� No. Compartments <br /> PKG. TREATMENT PLT. ❑ Dlstersce to nosiest, Wall oundalion fid_ Propert Low Method of <br /> LEACHING LINE L7 No.a Length of Ikr&s !,. T/WyalLlength/si:e <br /> FILTER BED Cl Distance to nearest WeN undation ^ ProPenT' Lina , <br /> sin <br /> SUMPS I I Distance to rwsrasl: Will,[ a oundelion_ PrOnert Ling <br /> ;;?L PONDS I <br /> I hereby cattily that I have prapwod this application and that the work will be dons in accordance with San Joaquin county ordinances. star&laws, and <br /> rules and regulattone of the San Joapuin Local Health District, J <br /> Home owner or licensed agent's sigrAtoro cendres the following. "I certify that in the P8dormance of the work lot which this permit is imoid, l shag not <br /> employ any poison in such marine,as m becoma subject to workman's twrnpensation laws of California."Contraeloi a hiring or sub-contacting signature <br /> "notion,the following. "I certify that in the parformence of the work for which this permit is issued,I shalt employ perso,,s subject to workman's conpensa <br /> tion laws of California." <br /> 1 The app cant (�/}st call for qunud spact ens.CompNu drawing on Yavaru lido, <br /> Signed x � Titla: _ s.,4 .. Data: <br /> 1/ FOR DEPARTMENT USE ONLY 'f <br /> Application Accreted by —�c'-'L..ar..._. -. _._ Date.�LSL1 yc^ 3 A <br /> PN or Grout Inspection by Gets _ Final Inspection by%/��% A��f�=l Dals�-/� <br /> Additional'comments: _0—K _ fc•A— -------------------_ _-- <br /> ❑ Stir 4564MI Ll Lodi 3699621 10 montan 823.71 L7 Trecy Bwsi 5 <br /> Applicant. Return all copies to: Environmental Neekh PermiUSarviue 1601 E. Harshen Ave., P.O. Box <br /> L 51e0�/O <br /> AMOUNT DUE A REMITTED RECEIVED BY OA <br /> 1"14 netv ,:., <br />