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APPLICATION FOR PERMIT ✓fib q <br /> ,. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1W1 E H AZELTON AVE:,'STOCKTON, CA <br /> Telephone 1209),46-6-Mi. �< <br /> f <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �f 1Complete in Triplicate} <br /> !' <br /> t tiJ 11, <br /> � <br /> "Application n made to the San Joaquin 1Local Health District for rmit to construct enols irtsteli tM wont henid daictibad.•T(iis � <br /> Rp he►ebYRa aPP : <br /> r <br /> ` made in compriance with San Joaquin County Ordinance No 549 for sewage or No.1862 for well/pump and the Rube andof the;Snt lorgilin <br /> a Local Health District .ty ; ,lasiarM ' <br /> w �6�/ . L/ire✓E dz� � � �r � i <br /> Job Address� City T�Lot Slag a PM �i <br /> Owners Name ` t. S' U Address. 4, <br /> Centractnrs P Address fid' � nF-1'r''FfZ (? cense No:f���'3�jI« �4 ,1 <br /> t TYPE OF WELL/PUMP NEW WELL G WELL REPLACEMENT C1 DESTRUCTION ❑ <br /> PUMP INSTALLATION.u SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST.;SEPTIC TANK SEWER LINES DISPOSAL FLD PROP�LINEt r: <br /> F AGRICULTURE WELL OTHER WELL ` PITS/SUls <br /> MPSx� . <br /> INTENDED USE TYPE OF WELL P_ROBL CONSTRUCTION SPECIFICATIONS ,y `~ <br /> ❑ Industrial;:. ❑.Open Bottom ❑ Manteca Dia..o aavation Dia"of WeM Caairtg�'. <br /> hCI Domm <br /> estic/Pate ❑Gravel Pack ❑Tracy- Type of Casing•'•' SpsciNcatiorts�� <br /> I:] Public ❑Other 13 Delta.. Depth,of Grout Seal Type of Grout <br /> #7 lrngation,; _.J;pprox. Depth '❑ Eastern Surface Seel metalled byt ° <br /> RepairUYork tone „fl` :;Type of Pwtip: H.P State Work Done` <br /> Well Destruction ":Well Diameter Sea!€ng Material(top Wl' <br /> Depth ' <br /> Filler Material <br /> Depth 56'1 <br /> x TYPE OF SEPTIC:WORK:::.:NEW INSTALLATION ❑ .REPAIR/ADDITIQN. DESTRUCTION u iNo septic system !is <br /> DESTRUCTION <br /> t a available within 200 feet?k � <br /> ' Installation vnll serve., Residence Commercial Other <br /> Number o4 l'mng units: Number of bedrooms <br /> Cheracterof,sol to a depth of,3 feet atei.table depths+ �' <br /> SEPTIC TANK �s� -;❑ Type/Mfg Capae€ty No Cnmpartmenta`x r4 <br /> P PKG..TREATMENT PLT;❑ Dralwsal f <br /> Mathad at <br /> r Distance to nearest: Well Foundation Property Line <br /> d <br /> LEACHING LINE `! <br /> No. B Length of lines 9d Total length/size' O Y iRz . <br /> FILTER BED ❑ Mawr.to nearest: Well Foundailm Property Line a <br /> eta + <br /> fry?z 4 t <br /> SEEPAGE PITS, ❑ ;DeRth "` Sim " Nurr.ber . <br /> JSUMPS a y D Distance to nearest:, Well,--L— Foundation Z� Property.Lirte <br /> _DISPOSAL PDNUS <br /> i <br /> I hereby certify that t have prepared this appiiratlon and that the work.will be done in acco dance with San Joaquinunty codrdinenees,'state'=lawa;�and' <br /> i... <br /> rides and,regu!stions ollhe..San Joaquin Local Health.District. r 4 �p ­ <br /> Home owner..or.licansed agent'_s signature certifies the following: 1 cetify rthat rgthe performancemit of the work for which this peris bauadrFl aha!not <br /> emplcy any person in such ma ras to become subject to workmaii's compensation laws of California:'Contractola lAr'or sub-contracting aignattrr� <br /> tarsi(ee the_fb4owing I. hat r7 the performance of the work for which this permit is Issued,'I shall employ persons subject to workman s cornpsrrca <br /> tion laws of California' 71 <br /> The applicant must c f gywred mplate drawing on reverse aide �r � <br /> Signed <br /> T+tie 000 <br /> Oete I <br /> is <br /> in <br /> FOR DEPARTMENT USE ONLY <br /> kppiicstion ACixrptod by' Data Aroe <br /> Pit or Grout Inspection by Date Final Inspection by /�% Dats F' + <br /> ditionat Comments t <br /> L Stk-',466.13781 G Lodi::3693621 ❑ Manteca .823-7104 ❑Tracy 83643M i <br /> Ayrticant Return all copies to'Environ ,tal Health Permit/Services 1601E Hazelton Ave., P.O.Box 2me Stk CA 95201 <br /> r <br /> FEE AMOUPIT DUE AMOUNT REMIT7fD CKs RECEIVED BY r DATE PERMIT;No <br /> INFO CA5H + , <br /> sIFM rpt <br /> - <br /> CH W25 <br /> rr t Te <br /> tL"yY fi.^ � M �iin <br />