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A. <br /> APpLICAmrj FOR FnRMIT <br /> i SAN JOAQUkN LOCAL HEALTH DISTRICT ; <br /> t+4tiS5 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Teleloorla (209)4W8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application h henrhy nada to the Sen Joaquin Local HpcM District f«a Pang%to construct end/or Yrar the work haruin deeabee.Thle aPO '1 ? <br /> rtiada in rort lance with San Joequkt County Ordinance No.so f«sewrapa«No.1882 for rneh/pump and theRrMa armReglrislbrte d to Son JequM•" ,F <br /> ' Local Health District. <br /> 5020 Mariposa Rd Stockttm, ttrt sly lOAC pM t <br /> F" "I.,V Job Adders <br /> 944-9325 <br /> Audry L Sufton Aaart 5020 Mariposa Rd Piton <br /> Owners Name <br /> i <br /> Self Saltie Pho <br /> Address License No. ne <br /> Contractor <br /> TYPE OF WELL NEW WELL Q WELL REPLACEMENT 0 DESTRUCTION O 3" <br /> [,Z- SYSTEM REPAIR C] <br /> PUMP INSTALLATION ❑ OTHER O <br /> , a . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP-LINE ��� <br /> FOUNDATION AG9ICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> * 0 Mantua Die.of Wall Excavation <br /> Cl I wsvw OPS morn Die.of Well Caelrq qq o <br /> G porriestitlPrivate 0GravelPack0 Trey Type of Spay' <br /> (F� 0 Public 0 Other p Delta Depth of Grout Sea[ Type o[Grout <br /> I <br /> 0 Irrigation -_,tpprox.Depth o Eastern Sul Sse1 hutalbd by Ys Y <br /> Repair WcA Dona [I Type 0Pump H.P. Sate Welk Done c.F <br /> h <br /> ❑ %Yell Diameter Sealing Material(top Cal <br /> < .Well prsrnictuYl <br /> Filler Material i } <br /> �. Depth h ptibre Mwer L� ]. <br /> TYPE OF SEPTIC WORK: NEW INSTALtATiON p REPAtq/ADDITION OESTRUCTiON{],1���wttNn =l ti xN dE , <br /> f Instrdletion will serve: Residence_f�Cornrtror W_.. Other <br /> L Number of fiving units: nn Number of bedroor i ti <br /> i Warn table depth <br /> i Character of coil to a depth of 3 teat: x740 �, �.t,ki�•2;9 F, <br /> SEPTIC TANK a Type/Mfg • r"' ' 1 �� CaPachll No.Co <br /> rt+partntanq � t <br /> ' 77 M <br /> PKC.TREATMENT PLT.❑ Method of Disposal <br /> 1 Property Una P� <br /> �1S Distance to nearest Well_ Foundation <br /> �^aCM4 <br /> ^� Total hrlgth/ <br /> h- No.&Length of lines <br /> LEACHING LINE Property Una <br /> .�' FILTE��@ <br /> RED <br /> Ll Distance to nearest: Well Foundation f _ .:;y:,:• <br /> Number <br /> ;'' SEEPAGE PITS <br /> Depth <br /> SUMPS O Dounce to nearest: Well Foundation Property Line ' <br /> DISPOSAL PONDSO ' <br /> 1 hereby certify that 1 have preparedthis eppliration and that the work will be done In accordance with San Joaquin WtmfY Ofdktancat.ams lawe,'and <br /> 7%"l rules and tWulatiorm of the San Joaquin Local Health District, in ysued.1 shag Ilot.. <br /> 1:'=i Homa awrw or licensed agvr&s signature certifies the 1010wi" -"I certify that in tfis perfonnarice of the work f« e*hk this r wA1- <br /> ' arlipioy any person In such mariner as to becorne subject to workman s oompensatiOn Iowa of Caldo rSe:'Contractors hk1n0 or euD oolweedng rOne <br /> 1 that in the performance of the work for which this pemdt is hstrad :ahsa empiol/iia subject w«krrien�a cm-Ow � <br /> certifies the f oaoweng:" comfy <br /> tion.%svgs of California.- i <br /> F4 : <br /> +, ions,Complete drawing nn reverse side• <br /> The appi"nt must call lot 09 <br /> required inspect C.- <br /> Sq f trb <br /> nad it. �'1'tTitle:T : Date: �! <br /> � <br /> FOR DEPARTMENT USE ONLY <br /> (�+/ Date Ares �`• <br /> AppGration Accepted by <br /> Date Final Inspection try 1Srye�Date tE1�Lx1+ <br /> Pit or Grout Irupectiori by - � <br /> Convnents. <br /> zxppE&m,:- <br /> wml Q Lod-i 3893621 d Manteca =1104 p Tracy 83&6386 <br /> Return all copies to:Emkorvrontal Heahh Pemiit/Servfess 18D1 E.Hazelton Ave..P.G.Boor 2009.Stk.,CA 9620i <br /> r: LEE AMOUNT DUE AMOl1Fri REMtTfEO GASH RECEn/E6 BY•. GATE ►E/IIliN7 NO. <br /> i INFO <br /> EN JIN lacy.I `74 pO i7 0. a foto BUD 8-I-S6 <br /> Ew 5a al <br />