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+- APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ <br /> a. <br /> (Complete in Triplicate) <br /> Application is heteby made to the San Joaquin Loral Health District for a Permit to construct and/or install the work andira quiteclinic tons This application Joaq is <br /> made in compliance with San Joaquin County Ordinance No.549 lot sewage or No.1862 for well/pump and the Rules end Requite tons of the Son Joaquin <br /> Local Health District. o <br /> Joe Addreu /I /[ `/^^ A� iL..&j y Ch�itn//}.SCIiS/�)^"�d/- -?_ Lot Siizze.Z PM <br /> 9/o5�yT0.CrCiT/a L.vECI.f CCiI. �r4 ne /a4$-5 �/O� <br /> I Address <br /> �. Owner's Nam n .��s ���,, Z/_[/.S/Oy <br /> '' rOn Y'S.Fsl7�7 a/zT./ License No.w7Gt' Phone -. <br /> L,1l;.�®..� D Aeeress <br /> Contracto WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPEOFA NEW WELL ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> a. <br /> i I PUMP INSTALLATION ❑ SEWER LINES — <br /> PITS/SUMPS <br /> PROP. LINE <br /> . DISPOSAL FL <br /> DISTANGE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL O <br /> �—FOUNDATION �— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing <br /> sees Industrial [I Open Bottom ❑Manteca Dia.of Well Excavation — Specifications <br /> ii Tracy Type of Casing <br /> ❑Domestic/Pr'rvale ❑Gravel Pack ❑ Type If Grant__ - <br /> ❑Other fl Delta Depth cal Grout Seal ,v <br /> ('1 Public Sm!a<e Seal Installed Dye-- <br /> 1 1 lingetion _Approx. Depth 1 I Easton) State Work Done_— <br /> ` H.P.__ <br /> Repair Work Done ❑ Type of Pump Sealing Material Itop 50'1 <br /> Well Destruction L1 Well Diameter F41e!Material IBBIOW 50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION v REPAIR/ADDITION I I DESTRUCTION I I IN availSePII1 tin 200 fee61 tedif public aevver's <br /> r <br /> Installation will servo: Residence✓ Commercial_//Other <br /> Number of living units:� Number of oomS�— Water table depth_1—SLS <br /> Character of soil to a depth of 3 feet: r 9A Capacity No. Companrrents <br /> a� SEPTIC'SANK D/ Type/Mf9�r / Method of Disposal <br /> PKG.TREATMENT PLT.❑ v1�2_ Foundation 10 Property Line <br /> Distance to nearest: Well _ / <br /> Total lengM/size <br /> r LEACHING LINE No.&Length of lines Qv ,^ropeny Lina�.— <br /> �M Foundation <br /> FILTER BED ❑ Distance to nearest: Well <br /> jl __Size Number <br /> SEEPAGE PITS b( Depth {A r Property Lina�---_ <br /> r Foundation <br /> SUMPS L1 Distance to nearest: Well�_ <br /> DISPOSAL PONDS n stain laws,and <br /> I hereby certify that 1 have PIBPared Nis application and that the work will be done in accordance with San Joaquin county ortlirences, <br /> t roles and regulations of the San Joaquin Local Health Distract. <br /> g g y compensation laws of Lalilomia:'Contractor's hiring o�subcontracting signature <br /> Hama owner or licensed a ant's ti uawra cartil'res the following: I<enlf that in the Performance of the work act which this permit o issued. I shat{not <br /> employ any person in such manner as to become subject to workman's comps rsons subject to workman's compensa- <br /> cenilios the lolbwing:"I certify that in the performance of the work tur which this Parma is issued.I shall employ pe P <br /> tion laws of California." �� ^ �� <br /> The applicant mu cab for all re Aired,inspections. Complete drawing on rever7 si Deal: [> <br /> x `)I'Cp Title: V <br /> Signed x <br /> - / FOR DEPARTMENT USE ONLY _ <br /> Date { 1� � Area <br /> Application Attaprod DV C Date <br /> Gam <br /> �� � Final Inspection b� <br /> P/I d Grout inspeetion py <br /> Additional Comments: 8237104 ❑Tracy 8356385 <br /> LOSik 4666781 ❑Lod) 369-3621 ❑Manteca P.O. Boz 2009,Stk., CA 9$207 <br /> rm <br /> Applicant- Return all copies to: Environmental Health Peit/Servkes 7601 E. Mezalton Ave., <br /> CK a RECEIVED aY DATE PERMIT'NO- <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH I3"(REV¢: ^>: U— <br /> En Wta <br />