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L <br /> L <br /> ` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466.6781 <br /> �e PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 11, <br /> describ <br /> This <br /> cation <br /> is <br /> h District for a <br /> V <br /> nco with Szo Joaqu n,County Ordinance Joaquin lNto.549 for sewage or Permit <br /> No. 1862 to,weNpump and the Rules end IRag lations of the Sani Joaquin <br /> aVigl. <br /> �Li�7l._ _ A CITY Lot Size PM <br /> a0. <br /> ,1 <br /> n�m..c-n,.ytom Address X111 r �I A) ♦ t-lY1�A Phone <br /> Pn (3oT<�b7 �' y' .License No 7YZ <br /> � 2 Phone ' IO <br /> A_Address, <br /> flUCT10N ❑ <br /> V t /PUMP: NEW WELL ❑ WELL flEPLACEMENT ❑ DEST <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> '.'I NEAREST: SEPTIC TANK <br /> SEWER I INES DISPOSAL FLD.__ PROP. LINE <br /> 4 _ FOUNDATION AGRICULTURE WELL _— OTHER WELL PITS/SUMPS <br /> Y` USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEGIFICATICNS Dia.of Well Caging <br /> ❑Open Bottom ❑ Manteca Die.of Well <br /> Excavation_ Spa ifications <br /> Private ❑Gravel Pack ❑Tracy Type of Casing <br /> TYDe of Grout <br /> — <br /> 171Other fl Delta Depth of Grout Seal <br /> _Approx. Depth I I Eastern Surface Seel Installed Oy <br /> Dgite (1 Type of Pump <br /> H P State Work Done— <br /> %ion ❑ Well Diameter _ Sealing Material Itop SO') <br /> Depth_ er Material (Below 509 <br /> r �•1IC\NARK: NEW INSTALLATION I I REPAI /ADDITION DESTRUCTION I 1 INai1 bpiµsystem permitted it public sewer is <br /> will serve: Residence ✓ Commercial—O dar <br /> Hing units_/_ Number)op�1L.7�poe_dr s - 12[J <br /> Was d soil to a depth of 3 feet:-4an —Water table depth <br /> ':K ❑ Type/Mfg ._ Capacity— No. Compartments <br /> Method of Disposal <br /> i MENT PLT.❑ <br /> Distance to nearest: Well_._ Foundation Property Li,__ <br /> L <br /> 'JNf L1No.6 Length of lines Total length/size_ -- <br /> ❑ Distance to nearsse Well Found34on Property Line <br /> it <br /> t. Sixe Number <br /> ITS I'! Depth .ylL.2--- r <br /> Ll Distance m neatest Well 1 n0 + Foundation� property Line�- <br /> PONDS flstate laws, and <br /> .dy that 1 have prepared this application and that the work will be done in accordance with San Joaquin county mdmences, <br /> bass :.tulations of the San Joaquin Local Health District. 1 shall not <br /> r or licensed agent's signature certifies the following:"I certify that in the peHormanca of:N work for which this permit issued, <br /> person in such manner as to become subject to workmen's compensation Laws of Cslifumis."Contractor's hiring c,suDcontracling signature -� <br /> following;"I certify that in the performance of the work for which this permit is issued.I shoal employ parsers subject to workman's comwn,4 <br /> 6. i CalJomia." r� <br /> ..a m t call for req eo inspections. Comdata drawing on reveres`itl� /tea fJ(J <br /> Ll/L.-(J— DEP <br /> �! IrJ Date: r_J—�t /� <br /> FOR DEPARTMENT USE ONLY _.� t-/_ z� <br /> Accept �Z <br /> Yie Date —"/G� Are <br /> Accept, by gg� <br /> Data 3T <br /> �rJ��,�"�_ Final Inspection by <br /> In � Date <br /> n spection DV — <br /> Uomments: <br /> 6 ti701 O Lobi 369-3621 ❑ Memo" 873.7104 ❑Tracy B35-5395 Silt.,CA 95241 <br /> Return all copies to: Environmental Health Permit/Services'501 E.Natation A.n., P.O. Box 2009, <br /> FEC AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATF. PERMIT NO. <br /> NFO �• <br /> `It 1 <br /> are <br />