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' - f <br /> APPLICATIDN,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {2osl ass-s�s� QC 4 19$$ <br /> r <br /> PERMIT EXPIRES 1 YEAR FROM. BATE ISSUED.. r.�1 <br /> ! i •. ! =fi':'7 i�'r. tx rf rt.�. �.- VIKJIvi'r <br /> r ;[ i ka. F. <br /> �( _ �� ., c'7�•#y��,;... .-, � '.,,;.:. (CoiCornplete,4n,,Trip icatel, � w� ti�i•,�c�P . :a, ��`�P�2fY?1`! i'�» .�- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heFain'desc_ribed.'-This application is <br /> limed"ern'compliariee=with Sdri Joaqum_County Otdirance`No.549-.for sewage br:•No:,1862 for.welUpump and;the Rules,and Regulations of theSan_Joagvin <br /> Local Health DistricU. ;, rtl .Ygt fir} 30a # ,1 7•.,i�Yt3 5'�F, iii - _' 1< its . 'c f' •f1kyW t� srrJE?E nq.(� GC{t!'1Ci <br /> 3C #Jf`irti, h cy.nt I 1 1 i x 1 n t i <br /> P f .?I Lt lw i, r 'i 2 � V0 1 i � i Cr 1 Ct L <br /> Job Address !9 I l-...,a r r:.J City Lot Size � PM, - <br /> _ _7 zz7 <br /> Owner's Name � i - Address- - - Phone <br /> r <br /> i­rT_.i <br /> Address I LO t � -._.. pG 1 ! Phone Gt �l w <br /> Contractgr. !cense No. � <br /> TYPE OF WE /P,U NEW WELL ❑ WELL REPLACEMENTp 1 DESTRUCTION ❑ �� r <br /> i t`1M INSTALLATION"'W`W-7---;�-SYSTEM-REPAIR-0 -OTHER O <br /> F DISTANCE..T.O NEAREST_--F '; -SEWER LINES�WELL- ' �OTHEgSAL FLD._ '" PRO_PI LINE <br /> OUNDATION AGRICUL URE <br /> _ • <br /> w WELLPITS/SUMPS �! <br /> "+- INTENDED USE 'TYPE OF'WELL; PROBLEM AREA-CONSTRUCTION SPECIFICATIONS' <br /> 1 4 <br /> - <br /> -1-L]A nclusitrialM- - ---G -Open-Bottom-- --w[- •Manteca-.•- •-Dia:-of.•Well-Excavation.• .- •.- I -_f_Diaof Well.Casing__. .I_.. _ <br /> p Domestic/Private Lil Gravel Pack ! ❑ Tracy '' Type of Casing I f J i Specifications <br /> f 1 Public n Other F delta, I Depth of Grout Seal k ! Type of Grout i <br /> a t �•F rriflaiion� »- .4pprorc Depth- �I,.1- astelrr .;_Suiiace.1SeaIAnstalled,by <br /> Repair Work'Done ❑ Type of Pump _- +bi. 1 H_P. l State;Work Done E <br /> I Weill Destruction ❑ Weil Diameter ' Sealing}Vlatenal (top 5-d"_1 <br /> F.fller-Material-fBaltiw <br /> R TYPE OF SEPTICjWORK; jNEW INSTALLATION 1 11 REPAIRVADDITION 1J DESTRUCTION 1 11INoiseptib system permitted if public sewer is j <br /> avail ableiVithih <br /> RI _ ercial vI Other <br /> __,.___n_allationlwill serveeserce rmm <br /> Number ofllinins units: Number;oi bedrooms <br /> to-a-depth-af13-fee't:--- - _-- <br /> SEPTIC TAMC ❑I T_le/MI I I I i <br /> _ iL_.Y f 9 No: Cort artments <br /> f Di I r <br /> PKG. TREATMEN� PLT. ❑ i rµ <br /> j 1 Method i Disposal <br /> " tance'ta n�a'iestPr <br /> Di <br /> I , i <br /> j LEACHING LINE , ❑• No'. & Len t of!rhes I e i f <br /> ! I 9 f�f l 1 Tota! Iengthlsize <br /> IM f3-6E-D- -fp;DiStanoe to nearest:-_^Welt '-Fdundatron i "i Progeny�rrfe- - i t } i ° <br /> I SEEPAGE PITS i I II Depth [ Size ? ! Number <br /> i ; _-i <br /> -- <br /> I --SUMPS'{ �--t- f Distance to-nearest:'i'We11 -*- `Foundation -f-- Property Lrne j --" <br /> �---DISPOSAL PONf7!�5 ❑� � I � ,I € i. ' � i 1 I I I ' i I € I ` � I a <br /> I hereby certify that I ave prepared this application and that the work will be done in accordance with San Joaquin county r <br /> q y ordinances',state laws, and <br /> L_ruIes and_regulations-oE- <br /> the,ySan-lloiacluin Loca3.diealth-District: •__.._r.. -__.-__ ,.� �___.. -�-.--=- �_F....-•---! ---f---�.___I__._ f - <br /> Home dwnerl or licensed a lint's signature certifi4s the following:I ! g! g g: "l certify that an the performance of the work for which this;Epermit is issued, I shall not <br /> employ_any_parson-insuch..rnanner-as-to.becomatsubiect-td workmanls.compensation-laws-of California.=;Contractor's-hiring-or•sub-contractingsignat ire----- <br /> certifieslthe following: '�I ce 'ify tFiat in,the performance of the work fog which this permit is'issued, 1 shall em lo` ' <br /> 4 rt p y per, subject to workman's compensa- <br /> # f_-,.L�•.-_l_...._J_..._ <br /> i Th�apalicant mu4t call or all required inspections. Complele drawing o erse side. <br /> _ ..Signed _ l i ! jTitle. Date: 1 FIS 1.w�W <br /> iFORf DEPARTMEf11Y SE ONLY <br /> 1 Application Accepted t y 1 j j i Date o ' -!I r <br /> Area <br /> I Piti or Grout nspection-by i j ! j I i Date Final Inspection jby pate I <br /> � Additional C mmants:� <br /> I l j i 1 <br /> IStk-}466 fi7$k 3--j B fedi. 36& 62a 4_ <br /> Ap6lica�t - Return all ople to: Environmental Health Permit/S'ervic4s 1661 E.''Hazelton Ave P.O., Box2009 StkL CA!95261 I I P I <br /> - - I ffE- ATJ�8T11J f 8171=-- -Amoy)*R'g`[v nrT` D ..._E.K.. ._ <br /> I i INFO C45H j j RECEIVED BY; 17 <br /> j D0.TE j jPERM1T'Np. _�. <br /> +.EH 1 3-241(REV.s <br /> r El-i 14.261 <br />