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APPLICATION EOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)4666781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> __—__---(Complete in Triplicate) --- <br /> Application is itw� matlo to me San Joaquin Local Health D.stuo for a permit to construct amt/or moll the work herein descrined.This epp6caten is <br /> made in con.pirance with Sen Joaquin Count,Odinanco No.M9 for sewage of No.1MR for well/pump and Ifm Rules are Ra niunions of the San Joaquin <br /> Luca)Huaigr D.nlict. <br /> saw Jab Atltlmss Cay ._ Lot Sisa PM <br /> rOwrroi a N[a�ma, ._ �Q.�A Address _s.c6sM'!�_ -s p L Phone �7� Q_ <br /> "s l <br /> Contract EA Address •�•`7 _License flo.�n-L—ZZ Pho4 3kt SI 05 <br /> TYPE OF_W_ELL/PUMP: NEW WELL C WELL III CEMENT Cl DESTRUCTION 0 <br /> s — PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER C <br /> DISTANCE TO NEAREST: SEPTI:•TANK SEWER LINES DISPOSAC FLD.__ PROP.LINE <br /> a� FOUNDATION AGRICULTURE WELL --_ OTHER WELL___ PITS/SUMPS _ <br /> INTENDED USE TYPE CF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �J <br /> •' ( rI Industrial 0 Open Sortam F)Manteca Dle.of Wall Excavation Dia.of Wall Caine _� J <br /> :1 Dgrfeatk/Pdvato 0 Gravel Pack ❑Tray Type of Cosine______ Specifications n <br /> reas FFF! 1"1 Pudic ❑]riser fl Delta Depth of Grout Saar' Type of Grout___—_._. v� <br /> e I I Irrryistw, _Afrynoa. Depth 1 1 Eastern Surface Seal Installed by _ <br /> f!j{i Pepsi,work Do." ❑ Type of Pump H.P. i _ State Work Done_ <br /> Well Destruction 0 Wolf Olamoter Sealing Material(top 50') <br /> aa. {' Depth "lar Material(Babe 60'1 _ <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I EPA( ADDITION DESTRUCTION 1 I INo septic aptem permitted it pudic sawn is <br /> eversible within 200(set.) <br /> 7i'• Installation"serve: Assidence Z Commercial_ Other <br /> Number of kving units:I Number nl ,act _-_ I rr <br /> Character of soll to a depth of 3 last:_ Water table depth 1 US 1 ' <br /> „ SEPTIC TANK Ll Type/Mfg Capacity--- No,Companmenu y <br /> ,Egf4t, PKG.TREATMENT PLT.O Method of Disposed! <br /> D'atano,to merest: Wall Foundation Property Lina <br /> xxxxxx if __ 1 <br /> LEACHING LINE No.a Length of!fines _'u.O Total length N <br /> aa n <br /> FILTER SED U Distance to rwmt: Well_,5.01 Foundation lot Property.U.n <br /> ZV <br /> was, SEEPAGE PITS 1 I Depth 77, —St.*. W Y IO Number <br /> SUMPS )i<Distance w nares: Wall Foundation 10Property Lind, S ___ <br /> } DISPOSAL PONDS 17 _ <br /> F I hereby..fly that 1 have p,apated It In application and that IDs work will be done In acco,danca w.th Sen Joaquin county ordinances,state laws,and <br /> rules and ngulatlopa of the San Joaquin Local Heals Carrier. <br /> y ,Fj Home owner or licensed agent's signature cani'es the following:"I certify that in the performance of the work for Whinh thus permit is sexual,1 shell not <br /> A employ,any person in such nanner as to become Subject to workman's compamation lave of California."Contractor's Mo nti or sus-contractk•.Signature <br /> cen!fies the folbwing:"I unify that in the parlomuf.:e of the work for which this permit is issued.1 shag O ncloy parsons a blect to workman's<uaWna <br /> JS don ewe OI California." <br /> Tho elpliun[ t cell 10,CI eq ed inspactena.Complsu drawing on reveres a�1,1/��/.�• ''' ��� """ o/1 <br /> 1r Signed Title: 1t 1Date: � � <br /> t; FORD PARTMENT USE OIJLY <br /> tP, A to tion AK. ted Pby -��+ -/- `L/� #I C21 � A. �� 2 <br /> V ¢# Grout nap tion by -fid"-y�- — ate mal i.._pection by Dex ���-y2 <br /> Addeional CoMin : <br /> IJ Slit 46547J1 0 LcJI 369-3621 0 Mentsq 8237101 0 T.acy B35-SM f, <br /> Applicant-Return a6 copes to:Environm'rMl Haa:in Permit/Service '&1 E.kruo"n Ave.,P.O.Boa 20O9,Six.,CA 96201 <br /> `1 <br /> INFO+ AMOUNT DUE '110UNT REMITTED LCASH TFCf':rEO BY (DATE / feAMR'NC <br /> /'7'od _ .9) r,Ll 2 Ll'-ty <br /> :J eel tea <br /> I ^ <br /> L <br /> L <br />