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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 456-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEC <br /> (Complete in Tripllcata; <br /> herby meds to the SA Joaquin Lural Health Dis:nct for a permit to construct end/or Amen rims work harem described.This appecsdon <br /> le <br /> .n cnlnplianre with San Jtlequkt County Ordinance No.548 hH sewage or No. 1862 for Well/pump and the Rubs and Regulatbm d iM Sar'JoaprYm <br /> Health Cisiriet. <br /> city Lot Sive <br /> address , <br /> i <br /> Address <br /> -,f,' I,� .� Phone*-,Name -f7l+��.GA�----�-' ��:�-__'_ ne <br /> Address -£v't-`�� License No. Ph"N" <br /> t m m DESTRUCTION <br /> E <br /> OF OF WELD NEW WELL C WELL SYSTEM <br /> EM£M ❑ <br /> _ OTHER ❑ <br /> - - PUMP INSTALLATION LI SYSTEM REPAIR ❑DISPROP LINE <br /> DISPOSAL FLD.�- <br /> TO.NCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> -- FOUNDATION _ AGRICULTURE WELL OTHER WELL <br /> INTENE`ED VSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI_ FI�CATIONS D'la.of Wall Casirq pC <br /> ❑Open Bottom ❑Manteca Die.of Well Esesvadon <br /> Industrial Type of Casing� Sp•cW"tions \ <br /> Domestic l Privets C Gravel Peck 0 Tracy,C Delta Surface <br /> of Grout Soa'' Type of Grout <br /> Public C Other <br /> $Ur1M�Leal inMdfled by_ <br /> Irrigation ­Approx. Depth C Fester State Work Done_ G <br /> qmr Work Dom G Type of Pump H.P. <br /> dl Destruction C Well DIari Seahng Material Itop 5D'1 _-------- <br /> Depth__.--- Filler Material 18e1m H puWk sewer b <br /> IPE GF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION DESTRUCTION C me'deblblet thin <br /> �P hart-I <br /> Installation will tens: Residence Commercial Odwr__o -- <br /> Number of bedroom s/ T <br /> Number of living units: __ Water table depth <br /> Character of snit to a depth of 3 feet: GpecHY No. Compertmeno - <br />.EPTIC TANK EJ Type/Mfg Method of D"I <br />`KG. TREATMENT PLT.C Eeo�wALim!>• <br /> Distanre to merest: Wa{ In property fir.. <br /> _- <br /> _ _ '>Z _Total length/site <br />_EA:HIN;I WE ❑ No.8 Length of Isms �,�D Foundtlbn Prooerty Lim <br /> sIU'ER Win G <br /> Distance to nsareAt: Wait •eLsa- --. <br /> A. Der __$Ire lit' Number <br /> BE PAGE PITS �f - F�g�gpg propnry Lim <br /> LUMPS G DHtsn:e to reatext: Well <br /> O SP(154L PONDS 7 _ �"'�'� <br /> 1 hereby r:rtify,'hat Ihave puDerod thin application <br /> Ar.d the:the work will Fe Com In accordance with San Joaquin county ordinances, nate laws.and <br /> rules and reguletipns of the Son Joaquin Lo-al Hoelth District. <br /> Nom9 owner l ions of agent's signature certifies rM follllownU: 1 c s comp <br /> at ensation n he Iawa of CeIHnrMa Crintracto`sl hiring Och this fwDcont rmit is issued,Isignaturedon t <br /> emplo-any parson In such manner as to become sutyec eons sub"ct to wptumn's oompa^se- <br /> eordnes the following:"I certify that in the peHotman+of the work foe which this permit is issued,'she"errmpbY pe <br /> tion laws of California." <br /> The 0Pplicant must call 1 r II r ui�inspectbrls• CaoPIeM drawing an revenue side. - <br /> ��t(y►� Q/�� . s'•r�_sw��f`.p4f/C Title: �.�+�.(.�J�--7✓ _ UetP: T <br /> Slpnnd X_!T f " ' I _ <br /> rl sv DEPARTMENT USE ONLY �. �pE� <br /> �i/-n` r Data -}�.-s- Ars�— <br /> Application Accepted W V_ t '� Deb <br /> / - Date Final inspection by <br /> Pit Or Grout Inspection W - G� <br /> JORional CmtT. -y--+- <br /> . Stk <668251 ❑ Lodl 3B9-362V ❑ Menten .7101 ❑ Tracy 83S618B <br /> Apall-.ant-Retum ae copies to: Environmental Health PerMt/Servk:es 1071 E. Hazelton Ave.. P.O. Bos 2005. Stk., CA EYu201 <br /> INF NT DUE AMOUNT REMITTED CA6H <br /> RECENED 0y DATE PERMIT NO. <br /> C7.y l�— S�zs11k'1 �� ZI�k3 <br /> r 1311IAN <br /> INM <br />