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`/ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 7 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 <br /> made in compliance%with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weil/pump and the work Rules and rein <br /> described. This application is <br /> Local Health District. Regulations of the San Joaquin <br /> Joh Address Ind <br /> City Stee*te'--- Lot Sire <br /> PM <br /> Owner's Name M r gt„rimes Address <br /> Phone <br /> Contractor Exnloratio Address 41 <br /> TYPE OF WELL/PUMP: NEW WELLLicense No.1+,$080.2—�phi <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK —NAA.— OTHER El <br /> LINES JQ) DISPOSAL FLD. PROP. LINE {,� <br /> FOUNDATION 55 AGRICULTURE WELL `S <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ orr ❑ Manj" t <br /> TW WeH Exca ion Dia. of Web Casing 2” <br /> ❑ Domestic/Private ❑ Trac <br /> Iii Publte <br /> to' <br /> f CorsiSpecifications .020 <br /> oeal 25' Type of GroutCement bento its <br /> 11 Irrigation Approx. Depth 1 I Repair Walt Dons ❑ lnstailed by Daturn EX loof Pump WeW tion © Do, State Walt Done <br /> r��lW// ter aterial (top 501 <br /> Filler Material ie 50' <br /> FYPEOF Ili— <br /> SEPTIC WORK: N LATION 11 REPAIWADDITION <br /> IN rmitted it public sewer is <br /> ailable within 200 <br /> Installation atipn vserve: R � rcial— Other feat.) <br /> Number of living units: Number rooms <br /> Character of soil to s depth of 3 feet: <br /> SEPTIC TANK Water labia depth <br /> O TypelMfg _ ty o. Compartments <br /> PKG. TREATMENT PLT_❑ <br /> thud of Disposal <br /> Distance to nee Well Conder Property Line <br /> LEACHING UNE ❑ No. &Length of tel length/size <br /> FILTER BED El Distance to nearest. tnn <br /> Property Line <br /> SEEPAGE PITS I I Depth Sue Number <br /> SUMPS 0 Distance to nearest: We" Foundat' Pr Eine <br /> DISPOSAL PONDS 0 <br /> I hereby cwWV that I have prepared this application work will be done in with San J <br /> rotes and MWARiors of the San Joaquin Local t, Oe4"r^ Y ordinances. state taws. and <br /> Home owner or licensed agent's sig"llwe certifies : "1 certify that in the performance of the work for vA*:h this porn*is issued,1 shah not <br /> wr4ft any PErson in such fnanner as to becom subpct to workman's <br /> certifigethe <br /> oorrrpensatian laws of California."Contractor's hiring asub-conhactirq signapnoa <br /> tion laws offo&y: •I csrMy that in the pertorrnance of the work for which this pemrt is issued.I shah employ psesons subject to workman's compertsa- <br /> The applicant must 7required tfspectiars. to drawing on reverse side. r� h-0 <br /> Signed Tide:- —�r=2' e- � /�� Data: / <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by Date �i Area <br /> Pit er Grout Inspection by Data Final Inspection by <br /> Dora <br /> Additional Comrrrefffs: <br /> ©Stk 466.6761 0 Lodi 389,9621 ❑ Manaca M7104 ❑Tracy 83644 <br /> Applicant- R@Wm aN Copies.to: EnwWonmerttal Health Penna/Services 1601 E. Hazekon Ave., P.O. Box 2009,Stk., CA 95201 <br /> FU <br /> F A&WUNT DUE AMOUNT ftE1YM TW <br /> .INFO H RECEIVED ByDATE PERMIT'f40. <br /> ..Hr t37r fKv,r Kat Ir 0 r') 117-?-, 1 1 '1. -7 or, I Its r1.f,T � <br />