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ZI I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6761 <br /> PERMIT EXPIRES 1'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 work herein described.This application is <br /> made in compliance with San Joaquin County Ordinanc l No.509 for sewage or No.Im for wvllpump and the Rules end Regulations of the San Joaquin <br /> Local Health Diindo.^�/JL� �/I [� ' /�/y ` <br /> Job Add. 1fa�?-0 ALs � �♦ ] City Lo*0 LLoottSo. �a PM <br /> Owner's Name `]CL/ omo Address 11�CSS,a� a_ (�� ® <br /> _ &;, PsA Phone `3 3],7 <br /> Contractor 4 4 Address 12FS1 Qhr&� aid %License No.-303 PhoneX <br /> TYPE 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 Cl Open Bona. ❑ Manteca Dia. of Well Excavation Die. of Well Caging <br /> ❑ Doneatic/Pdva,. ❑ Gravel Peck ❑Tracy Type of Casing Specifications <br /> fl Public ❑ Other ❑ Delta Depth of Grout Seal - Type at Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Saul Installed by <br /> Repair Work Done ❑ Type of Pump H.P. Slate.Work Dona <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I IN.septic system permitted if public sewer is <br /> available within M feet.) <br /> Installation will serve: Residence .1� Commercial then <br /> Number of living units: Number o/L���°M, <br /> Character of Sall to a depth of 3 f,C rJa Ou+� 1}Ih Water table depth .yam <br /> SEPTIC TANK V Typa/Mfg; OA)C Cxnadty a2 0 No. Compartment, -L-+ <br /> PKG. TREATMENT PLT.❑ �vw MetMtl of DDi/4�/'I <br /> Distance to n camal Well -col Fa,,&f,on,L iL Property Una 19Y <br /> LEACHING LINE TfNo. B Length of liens Total length/she (�Tv <br /> FILTER BED ❑ Distance to nearest: Well MITIA/ -Foundation Ik;O I Property Line S� <br /> SEEPAGE PITS GYDepth _aJ Sim Number ass <br /> SUMPS Ll Divan to,arm We113Sw Foundation avol Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby cartify that 1 have prepared this applicnitm and that the work will be done in accordance with San Jase In county ardinencas, Mete laws, antl <br /> rues and regulation,of the San Joaquln Local Heats DBtnct. <br /> Home owner or licensed agent's signature cartifss gee following: "I candy that In the performance of the work for which this permit is issued,I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California."Lonpacto's hiring or wbconpactirg signature <br /> cam iee the following:"I candy that in the performance of the work for which this permit Is bused,I shall employ panne subject to wmkman's compenu. _ <br /> Van lava of California." <br /> The applwa must cell alb quinad inspections. Complete drawing aver,side. <br /> Signed 1 no.: e7u7fl)" Dare: • " <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data r/ Ane p <br /> it Grout Inspection by ate y�q'S�1 Final Inspection by Data O <br /> Additional Commerce: <br /> ❑ Stk 466-OMI ❑ Late"3833UV--._Q Manual-M7106 - -0-Tal M54M- <br /> Applicant - Return all copies to: Environmental H,IM Permit/Services Ii E. Harahan Ave., P.O. Bos 2009, Stk., CA 96201 <br /> FEEINF AMOUNT DUE AMOUNT REMITTED DASH RECEIVED BY DATE PEAMR'NO. <br /> ..M tlalRn.r,aar 7U.G0 7ci.ov �Jk � 9 -/888 <br /> t„,�m <br />