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APPLICATION FOR PERMIT <br /> $AN ,}OACJ DIN. LOCAL MEALTH DISYRICi <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> - TelephDiie (.209) 466.6781 glin <br /> RERMIT EXPIRES 1'YEAR FROM DATE ISS00A <br /> (Complete in Triplicate) SEP 2 1 <br /> Applicatlon Is hQichy made to the San Joaquin Local Health District for a permit to construct and/of i,%90100 N N lion Is <br /> made In compliahce with$,yn Joaquin County Ordinance No,649 for sevvaga or No. 1B62 for well/pufnp and ltlyp(yjrgd/(01jyl�tJgpy�u�the San Jonqulir <br /> Local Heallh'Disuict. pay r 7�IYI { CtCVfl <br /> Job Address , ��3 Lam/ / I�W _ CieyV Lot Size PM <br /> Owner's Name rC <br /> Address Phono r'' " <br /> COnlractor P./ _ _,e_5Atldress LfcinSe No. Phone <br /> TYPE OF WELT./PUMP: NEW WELL 0 WLLI, REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATfON Ot� SYSTEM REPAIR Q OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK _ �SkAYER LINES DISPOSAL FLO.- PROP. LINE _ <br /> FOUNDATION AGRICULTUREIWELL _ OTHEH WELL . PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 FndustflaF 0 0 on Bottom Cl Manth�a DI 'of Well Excavation _ Dla, of Well Casing <br /> P � <br /> omestle/Private Q Gravel Park ❑7r3c� Tye of Casing_- Specifications <br /> III Public CI Other Cn Delta Oepth of Grout See) . _ Type of Grout <br /> I I Irrr9a6ort --Approx. Depth l I E�)sre n Su 6C6 Soul Inutallod by ��'r�r�r�...���```�����:��� <br /> Repelr Work Done L7 Type of Purnp �, .P, 11 Stela Work Dana .�Crrt <br /> Well Destruction 13 Well Dlarnoler Sealing Msteiisl (top 50') <br /> Depth �. Pillar Materla (Below 60') - _ <br /> t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RF kIR/ADDITIO I I DESTRUCTION l I (No capilc sy5 um penrdned if public Suwvr is <br /> ~` available wilhl t 200 fact,) <br /> � I <br /> �7 �instetlsll0n will serve: Residence- Commercial_r lr�ther <br /> r <br /> Number of Ilving units: Number of bedrooms r <br /> Character of coil td-a depth of 3 feat: <br /> -,-Water table depth <br /> �SEP_7IC 7QNK� G7. rypB4Mi6 � T�� Foundatlon <br /> uy NQ_CJpartmanIs _PKG. TREATMENT PLT.0 Method�f DlsposalDistance to nearest• WellLEACHING LINE ❑ No. S Length of linesFILTER BED D Distance tonearest: Weltn�. Properly Lina t <br /> SEEPAGE PITS I I Dopth _ SlieNumbarSUMPS Ll Distance to nearest Well Propany Lina L, r. <br /> DISPOSAL PONDS ❑ <br /> I horaby certify that i have prepared this application and thol tl` work wi 1tbo don0 in accordance with San Joequ n"Counly ordinances, state lawn, arxf <br /> rules and regulations of the San Joaquin Local Health Djblrlct. <br /> Home owner or licensed agent's signature cfirtifiea the following: "I cortif ,thel In the performahCe of[ha work for Lich (his Perin!'is issvod, I shall not <br /> employ any person In SUCK manner as l0 become subject to workman's.do pensatlon laws of California.`ContractRr;s hiring or sub convecting signature <br /> certifioa the following;"I certify that in the perform9noa of rhe work for wh c1l,thrs pormit is issued, I shelf em to <br /> tion laws of California." employ Persons trubject to workman'®componsa- <br /> The appllican�st call for all (0 ffrad llnspeeo/lions, Complete drawing on r arse side, <br /> Slgnod - <br /> _ <br /> APPlication Accepted by <br /> rFPR DEPARTMENT DEPARTMENT USE ONLY ? <br /> - Date- ` Area Z� <br /> Pit or Grout Inspectlon by Final InspectionC c. <br /> b � Data <br /> Additional Comments:_ <br /> Q Stk 466-6791 0 Lodi 369.3621 O Manteca 623-7104 ❑Tracy 636-&MS <br /> Applicant- Rotuen all copies to: Environmental Health Permit/Services 1601 E, Haz6hon Ave., P.O. B0X 2009, Slk., CA 95201 <br /> FEE AMOUNT DUE AR10UNT REMIT7E0 C <br /> INFO CASH RECEIVED 8Y DATE PERMIT NA. <br /> EH,-4-9d raw ,ruR �, _ - �f'r - <br />