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03-25-1994 03 01PM FROM TO 9460621 P-03 <br /> APPLICATION FOR PERMIT <br /> I1111 - <br /> SAN JOAQUIN LOCAL HEALTH DIS R1* Z <br /> 1601 E HAZELTON AVE , STOCKTO <br /> Telephone (209) 466-8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE <br /> . 0{Complete in Triplicate) <br /> INV <br /> Application is hoiaby made�o the San Joaquin Local Health District for a permit to construct and or i * ^ <br /> made in compliants with gain Joaquin County Ordinance No 549 for sewage of No 1862 for well/ <br /> -1.019 Shm <br /> Loea1 Health 3."`1= C r��t <br /> .fob Address �.� U � CityST(X__K^-Lot Sire PM <br /> Owner's Name W�T ..� �RZ� *ddr�lea, C� 04D 40 srocr � Phone <br /> STOCM") RSPB-13�I <br /> Contractor $pEg�TeJAAddress 21-S hhf ' License No.„:S:f Z .fik. P11one <br /> TYPE OF WELUPUMP ' NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLAT10N ❑ SYSTEM REPAIR U OTHER n <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 r� <br /> ❑ Industrial 0 Open Bottom 0 Manteca Dia of Well Excavation Dna at Well Casing <br /> Vc s Vats Gravel Pack 0 Tracy Type of Casing. t✓ o d Spec stations , ^ <br /> ("�1 u— ���& xOtl+er n Oei�a Depth of Grout Seal Al - YD f Type of Grout r"`�'r l x—i <br /> I I lmganon i--Approx Depth I I Eastern Surface Seal Insteiled by <br /> Repair Work Done L3 Type of Pump HP State Work Oone <br /> Wel} Destruction 0 Well Drarnoter Sealing Material(top 60') --�� <br /> Depth Filler Material(Below 60 <br /> TYPE OF SEPTIC WORNEW INSTALLATION 111 REPAIR/ADDITION! I DESTRUCTION I I (No septic system permitted it public sourer is <br /> available nnthrn 200 feel} <br /> Installation will serve RCfts roe Commercfal Other <br /> Number of Oving units. Number of s _� <br /> Character of soil to a dapuh of 3 feet Water table depth <br /> SEPTIC TANK 0; Type/Mfg Capacnty No Compam. nts <br /> PKG, TREATMENT PLT U Method of 01sposal <br /> ' Dnstance to nearast Welt Foundation Property Lute <br /> LEACHING LINE ❑ No & Length of tine, Tota!length/s6- <br /> -- <br /> FILTER BED CT, owtance to fteemat Well. Foundation Property Line <br /> SEEPAGE PITS I I Vapth Sire Number <br /> SUMPS 0 Distance to nearest Well Foundation Property Lens <br /> DISPOSAI.PONDS Ur <br /> I hereby certify that I have prepared this applroadon and blot the work will be done in accordance Hath San Joaqutn county ordfnanees, state laws, and <br /> rules and regulations of thelSan Joaquin til HesMh C41bict <br /> Hoe owner or licensed agent's signature cerdfles the following " <br /> Homo I certify that in the performance of the work fou which this permit is imwd,1 shag not <br /> employ any person to such manner as to become subject to workman's compensation laws of California"ContracWes hav+g or sub-contracting signature <br /> certifies the fotbwmg "I certify that m the pedortnancs of the work for which this parmt Is issued,I shag employ persons subject to workman s compensa <br /> tion la ofornia" <br /> The plicant m t tail for elf raoua n ors Complete drawing on reverse side. <br /> Signed Title• Date ..... <br /> R FW USE ONLY <br /> Date - ` Area_ 3 <br /> Agpt'tcaiion Accepted byder - <br /> Pit or Grout Inspection by Date Final lnspectlon by Dace <br /> Additional Comments <br /> 0 Stk 466.6781 0 Lodi 469-9621 ❑ Maniacs 823.7104 0 Tracy 835.6365 <br /> Applicant- Return all copies to Etwironmental Health PerffWSernm 1601 E.Hazelton Ave., P O Boz 2409, Stk, CA 8=1 •0/ <br /> L4 /d /"f1l <br /> { EE AMOUNT DUE AMOUNT REMiTrED CK RECEIVED Illy GATE Pr;RMrf NO <br /> INFO CASH <br /> nl o/ �7 <br /> 11 <br /> *EM 13-24JRW1/N61 dd 1f oQ y�i L/ <br /> 9F4ri IA-28 /� <br /> /!1 r/ f <br /> TOTAL P.03 <br />