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APPLICATION FOR PERMIT -
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
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<br /> 1601-E. HAZE'-TON AVE., STOCKTON. CA
<br /> Tc!ephrne (209) 486.6781 t L!p 19 10^.? C_ n ';
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUER
<br /> (Comp)ete in Trip(ica!(A
<br /> - Application r5 heryhy matter io the San7UAruin t,ocat}tra•!h DiSlriGt fora p2ur:t to roncg,;ct and.or sn 6mr rho-wnrk hrtpin described.This appilcatian is
<br /> mddC in r.Om,!IIr+CC wits,San Joa�wn CCunty Ordnant.e."+:,.5.19 for se.w.rur.ni f:a, t!tG2 for well'ptimp and rhe Rules ar,d Regulations of the San Joaquin
<br /> . - Local rfealth Drstrirr.
<br /> - -., .. .. Joh Address .a '7 � 1 C:ry.! i.rrl. it%1�:Ln:Sit, FM ---
<br /> . Owner's Nam fir' l t t�;l'1 nt'C•ess ._.f-_�.[ .--.L 1v1 `;• r. _Phony -
<br /> r r
<br /> Contractu•'s'-am" �.'_�``-a-a.�.�-l!,. y{�,`'-__.iFL - _, L;cCns^N,;.
<br /> t_Ld _ one _::_li f• 'i r,
<br /> tp - TYPE OF WcPUMP: NEW WELL -, WELL REPLAC;_MFNT DESTRUCTION
<br /> _---..__....,.........- ._._._
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<br /> PUMP INSTALLATION SYSTEM REPA!? OTHER .
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<br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.._ -_._,— PROP. LINE -
<br /> ' - FOUNDATfON _, ... AGRICULTURE WELL OTHER WELL_-,_. PITS;SUMPS
<br /> i• V4TENDED USE' TYPE OF WELL PROBLEM AREA CC.'ISTRUCT!ON SPECIFICA11ONS
<br /> Industrial ,'Cpq $nrtrm . : R,'.an!cca.... . Dt.: r,1 4Ye{ EywvattonT_�_—---_-- 'Dia-of Welt Casing
<br /> !<
<br /> Domestic?Private .T:GravHiPatk --Tracy Tyne pf(,astntt Specifications
<br /> . 'I Public OIk4r - br1!a Depth n'C-ow Sear Type of frrout_ -
<br /> - - L'!Irrigd!ion - __..,.Apprnx.Depth E45tern Sur•l:n"Scat tna;,)ff,d tri
<br /> .. .Repair Work Don -[.. _Tyne of Pur:p ..._,_.".- ._-- H p __, _ State YJo:k DG.rr
<br /> . 1 Well DestruCdon - Welt DiMne!or ._.----•'--'—'_--
<br /> .i. F•I'er V.p?rnai rR.Kcrov
<br /> -TYPE OF SEPT3C WORK: NEW INSTALLATION 'REPAIR:ALDIT:ON GESTR.UCT!CN~; iti.o septic system permitted it putrlee Sewer is
<br /> : - av9ilab3e within 200 feet.I
<br /> r .
<br /> InctaRatic. will st•rtie: Residentr_. .. Cammerct i._ Other., (�
<br /> Number of lkrinq units:'__.L_. Numbw of beolwms:
<br /> r� �• ff '' l :,Ir •h
<br /> n r t . ! rt o a d-z th of 3 feet: Waver:a r1c
<br /> C a ac 1:"0 50 2 P P.
<br /> SEPTIC TANK XTvperfvtfp CGi�I..-kt,1 __.: Capacity --��, �_ No.Compartments
<br /> c PKU.TREATMENT PLT. Method of Disposal V
<br /> L
<br /> - D.stanr-n,to nearest: _ Well__/Jf-! Foundatipr— --_ Property Line 41!'r1
<br /> 1 �
<br /> ! r �/ —1
<br /> LEACHING LINE � Nr,,8 Length of firesr. =,7�.,�.,�t11_�_�_.._._ Tora!
<br /> FILTER BED Oi5tance to nearest: Wdt_ Foundation____ Prope;Ty, Line
<br /> SEEPAGE PITS Depth ;y.,G_�'7_Sue.___. .: i_�"T�'___- Nwrbeir_ L — -
<br /> ..SUMPS ' Distance to nearest: NJe!f JJC,' Fo.ndaoon_ �•-- P•aperry Line
<br /> DISPOSAL PONDS D _
<br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joxgw
<br /> uin county ordinances,state las,and
<br /> rules and regulations of the San Joaquin Locat Health District: -
<br /> Horne owner or licensed agrnt's signature Certifies the fottowirg:"I certify that in the performance of the work for which this permit is issued,I shall no:
<br /> employ any person in such mannet as to bacorne subject to workman's ccmver5ation taws of California.'•Contractor's hiring or iub-contracting signature
<br /> certifies the following:"I certify that ir the p;rlormance of the work for which this pbrmu is issued.I shall employ persons sunjecr to workman's cdmpensa-
<br /> lion taws of Califomia - - _
<br /> The applicant trust call
<br /> for all required}inspections.Complete drawing on revefw sideS. - -
<br /> Signed)1___t
<br /> FOR DEPARTMENT USECNLY
<br /> A Plication Accepted bV 2eQ.,C Date
<br /> j %`f i k li _ Final Inspection by / ' z
<br /> Pi rGf.Inspection by�iJ- � Dare__�` ! t +"� Data J
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<br /> c St} 466.67'8! C Lodi 369.3621 %?Manteca EM-7164 i Tracy 635&135 - -
<br /> �AppPicant•Re 8111 cupie,rw Environmental Health Perr>:t!Services 1MI E. Halol?nn Ave.,P.U.Box 2009, Stk_CA 96201 �—
<br /> .r F - AMC" DUE - AMOUNT RE.4rlTir�.ASH REC£IVEI)11Y DATE P£RMIT'NO.
<br /> r.N 1124 IRF1r.i0tR7• '+1�' I/'Y`.) lfl"_7.vJILC'�'Iry ,rr / f. / ;_�,!•�c (' )�1 /
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