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APPLICATION FOR,PERM IT <br /> .w... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> !,-,h If, (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insmil the work herein described.This application is <br /> made in compliance with San Joaquin County Ordistance No.649 for wwage or No.1$82 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health DWrict. <br /> Job Address ! 7 � l D d)q J n IJ City�Q .Let Sim_o " 3.1 PM <br /> r _ <br /> t •Owner's-Name dress ^� ,�y�•j `_, t-`� ' �` ! <br /> Contractor's Name ,Licaneo <br /> f <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT•© DESTRUCTION d <br /> PUMP INSTALLATION SYSTEM REPAIR 3UK-)6- �y. �" OTHER 0 t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i` DISPOSAL FL D PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL ,PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS 1 <br /> _ m <br /> .s Industrial C:l Open Bottom Manteca of Wofl Excavation^.._ Dia. of.Weil Casing <br /> ( Domestic/Private G Gravel Pack L Type of Collin Specifi�at�ons 3 <br /> �Pubfic,, i �ti 0 tither O D L7eptlt of Grout Seal Type of Grant <br /> ti)� , °` ', l t r I <br /> C' Irrigation + ', --L-Approx. Depth astem ace Seal Installed'by _ <br /> Repair Work Done i Type of Pump H.P. State Work Dona r <br /> a <br /> Well Destruction J Weil Diameter Sealing Material(top ) { <br /> Depth _ Riot Material {Below 50') I S a <br /> s TYPE OF SEPTIC WORK: NEW INSTALLATION .REP0 (No septic system-permitted if pubUC sewer is <br /> i z available within 306 feet. <br /> Installation will servo: Resic4anxxr CBmmercioi-i, Other <br /> Number of living unrts: Number of btidropme _ <br /> Character of soil to a depth of 3 feet: + �+ i WBtar tablo cihpth ' <br /> SEPTIC TANK Type/Mfg i_ o q ° -Capa6ty ,� 'd' No. Compartments <br /> } PKG. TREATMENT PLT.G 1t ^^M^ �` `' / Method of Disposal I <br /> +); V�yUj l�terZe'�tbwrn�e�rssrr�«---Wel . <br /> Foundation j 9 Property Line <br /> LEACHING LINE ( No.& Length of lir*s ,1.lt T, ,length/ji. size T— -- <br /> FILTER BED O Distance to nearest: t We9 _ Fetata (ort -- Property Line - <br /> SEEPAGE PITS n t Depth J Nurn6or ! <br /> SUMPS Distance to nearest' Well. 'Foundation Property Lina._._._..'-, <br /> } DISPOSAL PONDS E] .• � � <br /> I hereby certify that i have prepared this-application•and that the work will be done in accordance with San Joaquin county ordinances, state lays,anti , <br /> rules and regulations of the San Joaquin Local Health District. <br /> ` Home owner or(!tensed agent's signature canifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> { ,employ any person In su manner aa°tabecoma subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 111! <br /> Certifies the g:,' ce that,in`the performance of the work for which this permit is issued,I shall amplaV 45ersone subject to workman's compensa- j <br /> tion laws of= <br /> I The applicant mus 1l t o ions. Complete drawing on reverse side. <br /> Signed \ Te: Date: _L 1 -- <br /> Ma.3 } <br /> FOR DEPARTMENT USE ONLYIt Ile_ / <br /> Application Accepted by _ Date i A I <br /> { Pit or Grout Inspection by �,.�. ._"`` .Oat's �Fnw Inspection by DW <br /> ,Clditional Comments: °`- <br /> ... i S*`tk 4f36-M1 Ci Lodi 389-366`'21'`^+ C 1b1�823-7104y C'3 Tasty SM <br /> '',nt- Return all copies to: Environmaf►ial Health Permit/Servi+c"IMI E. Haz0kat Ave., P.O. Box 3009, Stk.. CA 95M1 <br /> ♦iNFO AMOUNT DUE AM04JNT AFMlTTED � 5H RECEIVED By DATE PERMiT'No. <br />