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APPLICATION FOR PERMIT <br /> sAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4®6.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tr;pllcatM) <br /> Applicotion Is hereby made to the San Joaquin Local Health District for a permit to construct and/or Kotan the work herein deKrlatl'at k OPPNCSon JoagtuIS <br /> mads M compliance with San Joaquin County Ordinance No.649 for w^"*or No.1962 for well/pump and the Rules end Requletbna <br /> Local Health DNMICt. <br /> Job Address y S" /�/L� City Lot Sita :X�C - PM <br /> Owners Name /�'F�.Sf CFIiC'CC- Address S�?/`7/ __ Phax <br /> y <br /> /S 1^tiJ License No. -C 5 y 3"/S Prato`A 4 <br /> Contractors Nance• (� . <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION L) <br /> PUMP INSTALLATION C SYSTEM RFPAIR C OTHER C V1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLO. PROP. LINE rV <br /> FOUNDATION- __AGRICULTURE WELL _ OTHER WELL PITS/SUMPS __ V) <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 73 C Industrial O Open Bottom D Manteca Ow. of Well Excavation Dia. of Well CSOWV <br /> Domestic/Private C Gravel Pack M Tracy Type of Casing_-__ Specifications <br /> Public Other E Dela Depth of Grout Seal Typo of Grout <br /> Irrigation _�pwox Death � Eastern Surface Seal Installed by.— t/ <br /> Repair Work Done G Type of Pump H.P.---- — Stats Work Done <br /> Wen Destruction C Weil Diameter Sealing Materiel(top 50'1 --- -- - - <br /> Depth Filler Material leek)%i 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION RF-AIR/ADDITION ❑ DESTRUCTION 2 INSeptic" ph If p'�sower k <br /> t <br /> Installation will serve: Residence COmrMrciri._ OthM -- <br /> Number of living units: _/ Number of tedrorms Of <br /> Character of son to a depth of 3 feet: �'%�1' Wow table depth ZZ <br /> .,/ No. Companmer"s <br /> SEPTIC TANK Typarf+Mg GPK��•� Method of of Dig _ <br /> PKG. TREATMENT PIT <br /> 0+ FotarMlatlbn 1�' PropMy Lim <br /> Mance to rraerest: Wen.- - <br /> — <br /> LEACHING LINE Y No. 8 Length of lines Toth � <br /> FILTER BED Distance to nearest Wen Fouftdallon 7'C Property Line_..5 — -- ' —- <br /> SEEPAGE PITS ❑ Depth � 'Site — Number—_ ------ <br /> SUMPS C Distance to nearest: Well— toundatwon —___.--_ Property Lm <br /> DISPOSAL PONDS <br /> I hereby cert AY that 1 have prepared this appiw Action and that the warn vin be done in accordance with San Joe luin county ordirnannces, a"c iv rs,and <br /> ribs and regulations Of the San Joaquin LOCA Health District. <br /> Home owner o licensed agent's signature Cem"41 the fohowirg. '•I certify that in the performente of the work for which this f oUb- is issued. <br /> *Ctin I shah not <br /> employ errs parson m welt manner h to tteCOrrna au to workman's compensation bawl of California"COnntfactOes hirMtq a cab IantraetMq llgrNture <br /> csrWiss the following:" <br /> 'l tertian that in the poAompnte of the work for which this psrrrnt ti issued.I shall snnpley peas wblect to workmenn's CO"Vanea- <br /> tion laws of California" <br /> The spolk'ant moat call for all required inspections. Complete drrwing on favor"9 / <br /> Signed lt_ <br /> FOR DEPARTMENT USE ONLY <br /> k p; Area <br /> Appaca[ic�-%Accepted by / `�l --- Dab A <br /> � � r•'�- Dela <br /> Pit or Grout Inspect`o' by — Date ---.----- Final lnsPWrion by r--" <br /> A! <br /> Addino+al Comments _- <br /> X Srk 466-6751 _ Lodi 3W3621 ;- Manteca 8237104 Tracy 6764756 <br /> Appacam - Return .In copies to: Enwonfnef Health ParmitServic"1501 E. Hatelton Ave., P.O. Box 2005. Stk.. CA 9x120/ <br /> i fEE ♦MOUNT OUE AMOUNT REMwTTEO CASN a[CEIvED 6�101A <br /> t . <br />