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APPLICATION FOR,PERMIT <br /> SAN JOAQUIN LOCALHEALTH DISTRICT <br /> 1601 E. HAZE—ION-AVE, STOCKTON, CA <br /> Teleo6rna (209) 466-6tl- <br /> PERMIT EXPIRES ?b")t 10 e?e It to c'� <br /> 0,7, "r.. '`UIO(11,29 JJOti.ICOlllplet8-•IO <br /> T cla <br /> ripli -j�,t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hericin,aescribed.This is <br /> do in lfi,a�nLce 2w"fthis', ' <br /> San Joaqtdn.County 9rdinance No.649for sewage or No.19821or well/plimp and the Rules and Regulations of theSan Joaquin <br /> Local Health District.,OII!� e n - Ae <br /> nit'nsfrio:) to w-ol le� lbe�qzib 9:�Fvv4 7e.V <br /> Im! .pi, IP y`+' I,q sn� rJeT r if) ?wlt�si "IrTtIV, Pl,vyj Prftn t0_rp-,11:1"11J 4 <br /> Job Address �e Z ogtWAlLot 12i Aeo PM <br /> Omer's jj;" -ZAwx--;c- k,;9,0Vr Address Phon <br /> Contractor's Liclisic, Phone --X�- 46 6 7 <br /> Nemo 1&�EO—A(S No. <br /> TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT 0 j DESTRUCTION 0 <br /> PUMP INSTALLATION El SYSTEM REPAIR 0 # OTHER o <br /> DISTANCE TO NEAREST: SEPTIC TANK DISPOSAL FLO— PROP. LINE. <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial D Open Bottom 0 Manteca Via.of Well Excervation I Dia. of Well Casing- <br /> 13 Domestic/Private0 Gravel Pack r)Tracy Type of 691 Y r Specifications <br /> 0 Public 0 Other 0 Deltec k e vas Z 6;ift 0 Grout SI Type Of Grout <br /> — <br /> 0 Iffigati6n --L-Approxi Depth .0 Eastern Surface Sell Installs d bYr <br /> Repair Work Done 0 Type of Pump H.P Gelate Work Done <br /> Well Destruction 0 Well Diameter Sealing Material Itop 51Y) 09 <br /> Depth Filler Matiftl (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION�M-REPAIR/AODITION 0 DESTRUCTION 13 (No septic system permitted if public sewer is <br /> available within 200 fest.) <br /> Installation will serve: Residence-ZiCommincial— r <br /> rifts: Number of bedrooms -7 <br /> Number of living u JL <br /> Character of sail to a depth of 3 feet: —Water table depth do IF <br /> srpTic TANK jB10'Typ9/Mfgi 46 A.0, Capacity— No. Compartments <br /> PKG.TREATMENT PLT.0j� Method of Disposal e� '�46�ridstkm _ Property roperty Una ZdO <br /> I. Distance to nearest: Well <br /> LEACHING LINE 2-*No. &Length of lines Total length/sin <br /> FILTER Bb LJ Distance to neareen;. Well fWt Foundation .2,0 Property Line <br /> SEEPAGE PITS L7 Depth Number�3 <br /> ,SUMPS O' Distance to ne+ast: Well oft Foundation 20 r property Una--:/DO11 <br /> DISPOSAL PONDS 0 <br /> ,I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin county ordinances,state Ism,and <br /> .rules and regulationadthe-San'Josittin Local Health District. <br /> . 7 . 1 <br /> Mom owner or licensed agate's signature certifies the following; "I certify that in the performance of the work for which ibis permit Is issued,I shall not <br /> employ any person in such manner as to beciiine subject to workman's compensation laws of California."Contractor's hiring Woub-contraicting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shelf employ persons subject to workman's comperes- <br /> ) . ..tion Is"W-Galifornia" . . I -+ + <br /> The applicantca 11 for so required inspections. Complete drawing ori revemjklp- <br /> - <br /> Signed. Title: Date: <br /> l FOR DEP ENT USE ONLY <br /> Application Accepted by, Date Area <br /> C�t, —JOLL Fire,Inspecti ri by Date <br /> Fit or Grout Inspection by <br /> ,Additional Comments: <br /> 0 Stk 466-Ml +- 13 Lodi 30-M10 Manteca 823-71104- 11 Tracy 836-6316 <br /> Applicant-Refute all copies to: Environmental Health Permit/Services 160I E.Hankon Ave., P.O. Sm 2009, Stk., CA 95201 <br /> 'AMOUNT D61 --ftRMWNO. <br /> INFO <br /> +SH 13-M IMV,101 45, C4ej <br />