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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVF., STOCKTON, CA <br /> T011306hi 12091466-6781 <br /> PERMIT EXPIRES 1-YMAR FROM DATE ISS E0 <br /> 1Compfeta in Triplicate) <br /> Application or No.1682 for well/pump and the Rules and Regulations of the San }oaquin <br /> is ha,eby,nada[o the San Joaquin Local Health District for a permit to construct andfor install the work herein described.This appilrau cl is <br /> i made in compliance with San 30a4uin my Ordinance WG-649 for sewage <br /> Local Health District2Clty PM <br /> 19 <br /> ;lob Address <br /> c� �� Lot-size <br /> Photse <br /> owner's Name �_p hone <br /> �� <br /> Address <br /> Cantractar DESTRUCTION <br /> NEW WALL tl . �. <br /> WELL REPLAGEMEN7 .13 <br /> OTHER <br /> TYPE OF WELL/PUMP: �..._SySTEM-REPAIR-9 , <br /> PUMP INSTALLATION t] A}SPOSAL I GD. PROLINE y <br /> =SEWER LINES —� PVTSISUMPS <br /> Ik p4STANCE TO fdEAREST: SEPTIC TANK �— •'�"�""'�^'OTFiEgyy� <br /> FOUNDATION - j(GR}�ULTUFiE WELL �� <br /> 1NTENOED USE TYPE OF WELL,...,..rPq�� CONSTRUCTION SPECIFICATIONS <br /> D Well <br /> ~� O Open Sottam - 0 manteca Dia.of;Weri Excavation�—�—r <br /> C) <br /> Induatrial Type of:C tsin Specificatiom <br /> Q Domestic/Private Ci Gravel Pads 0-Tracy. r Depth of Grout Seal Type of Grout —' <br /> Cl Other # }-i Delta _ <br /> i"i PuttGcSurface Seal Installed by <br /> 1.1 Irrigation _.r..Appmx•Uepth 1 I Eastern State Work Done <br /> '' H-P. <br /> -Repair Work Done 0 Type of Ptrnp Sealing Material Itop 50'1 <br /> k Well Destruction 0 Was Diameter Filler Material ISatdw 5(r)Depth ;' I <br /> 1 TYPE OF'SEPTIC•WORK: NEW INSTALLAT46 i7 �E /ADDITiO itESTRUC7ION i 1 available feeit'ed if is sewer is ' <br /> installation wis serve: Residence— Col,tmercial ,` Other [� _ <br /> Number of living units: Number of bedrooms CroC•aQ Water table,depth <br /> Character of soil to a depth of 5 1?10. �pacitY �� Compartments <br /> SEPTIC TANK �I ype1 fg _ ethod <br /> of DisposalPKG.TREATMENT FLT. ,�!'O`A>��� Ptd <br /> tine <br /> Diest <br /> marrce.to near : Well Foundation <br /> . - I+ - �_ .Zdat*!6_2C <br /> ytai lengitYl�ixa <br /> i LEACHIAIG LINE i7 No;�f�LeirOth of Line — <br /> D Distance to nea ---- °peal' t <br /> { FILTER SED a "~ <br /> I ].I Depth Sizer Number _ <br /> SEEPAGE PITS ; - foundation Ply Una <br /> 5l1aAP5 Ll f Distance to nearest: Wall - -.. e• ,,rr.- �..� <br /> -,_ <br /> DISPOSAL PONDS �! ordinances,state faw9 iui <br /> I hereby certify that I have prepared this appticatbon•and that the work will be done in accordance with San Joaquin county <br /> rules and regulations of the San Joaquin Local Health DiRtiict. i 1thet in the peAorrnatwe of the work for which[his permit 1e mm8d,1 dwil not <br /> r Borne owner or licensed'agent's.tepnatwe cartifres the fallowing:•, <br /> s mVloy any person in such manner as to'baeorne subject to vmorkmeds oompen�n of, ed.I"ll employ <br /> p&w usb �s,u wocktra n's c simpsma--� <br /> certifies the following:"4 oattify that in!he-perforrr,ar '7esf the vAA for wbldh this permit is issued.4 sha11 employ Perstrns suhlecf t4 workman's�rrg3artsa <br /> tion laws of Californle." v ^ r <br /> s�. <br /> 1 The ap moat call for all required inspectiorta•Complete drawl favarso side. <br /> y -"'rte. �• .r- <br /> �' ~ Title: <br /> Signed 4 <br /> _ DISE ONLY <br /> Date <br /> Apprxatlon Accepted by <br /> Fii or Grout Inspection by r Date ' <br /> Additional Comments: •�+ , <br /> ❑Stk 46&M1 O Fadi �-5621,••_ -' O-j nteca 182,3-7104 ©Tracy'•3&6385 +* <br /> Applicant•Return all oop}ds to• Environmen � <br /> tal Hea4th Fetiservices 1601 E. Hazelton Ave.. P.0.sox 2009.Stk.'CA 85201 <br /> FEE OUNTiDt1E AMOUNT'REM I7TEo CASH Rf�ENrED ByDATE <br /> Q� PERMIT'NO. <br /> INFOLD <br /> EH 14-30 .,, ... - ...�y. ....4. <br /> S <br />