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MY <br />•Y � t - IAF - � �} <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA i <br /> Telephone 1209) 466.6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUE=D <br /> (Complete in Triplicate) ff' <br /> t <br /> Application is heiaby made to the San Joaquin Local Health Dislncl for a permit to construct snifter install the work hatein described.This application is y <br /> made:n compliance with San Joaquin County Ordinance No.549 Jet suwaga or No- 1862 for well/pump and Ilia Rulas and Regulations of the San Joaquin : <br /> Local tteahh District. <br /> • r <br /> Job Address 4✓r 1�IQrs?4vr L 1+1. PM_ r <br /> City Lot Size <br /> m?co parbl¢c,,.,, *2000 AlrMerrq cle fGs �c1s <br /> Owner's Name_�rrirlc,r#+. tni.,is. Address .44-% MGf y Phcne 1� 9733 Contractor S! L-K �Address(�� f License Na,LEi��,£�phone TYPE OF WEL�lPUA9P; NEW WELL L7 WELL REPLACCMENT ❑ DESTRUCTION L7 <br /> PUMP INSTALLATION 17 SYSTEM REPAIR l7 OTHEA�Rt�veDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _, OTHER WELL PITS/SUMPS INTENDED USE Tl`4"JF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial '� ❑OpenBottom Cl Manteca Dia.of Welt Excavation�� Dia.o!Wel!Casin <br /> 0 DOmesficfPsivate t16 Gravel Pack ❑Tracy Type of Cssing--J��� Slxcifiutiens <br /> 1'I Public ❑other n Delta Depth of Grout Seal —73(21EL <br /> pe Of Grout C Cyq <br /> I I Inigahon (QQ APINox.Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type OI Pump H.A. St <br /> Well Destruction ❑ We"Diameter I/ <br /> f �� Scaling Malarial flop 5011 <br /> I'`7frx.wt WMtfdtaflw'pePth Filler Maierial 18elow SO*)TVRf ' <br /> OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADOITION 1 1 DESTRUCTION 1 1 Me septic system permitted if public%ewe ' <br /> available within 200 fect•1 <br /> Iv'd itionoriResidenca z Commercial Oth•; <br /> 1`11..,er of living unit:-. Number of bedreoms <br /> Character of soil to a depth of 3 fee, table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments <br /> PKG.TREATMENT PLT.0 <br /> Method of Disposal <br /> Distance to nearest: Well ation Property Line <br /> LEACHING LINE Cl No.3 Length of tin length/size <br /> FILTER SED erestWell Foundationd <br /> Pr Linevi ; <br /> SEEPAGE PITS t I Ooplh ___S; <br /> Number <br /> SUMPS I Distance to nearest: Well Foundation Property Line <br /> DI AL PONDS LI <br /> =<I hereby Certify that I have prepared[his application and that the work will be done in accordance with San Joaquin county ordinances,slate laws,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies 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 such manner as to bacome subject tO workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cenifies the following:"f certify that in the performance of the work for which this permit is issued,I shaft employ persons sub;ect to workmar's compansa- <br /> tion laws Of Calif Ms.- 1 <br /> The applicant us call for x71 r ire inspacti s.COmplefe drawing on reverse side.C 'q,� ,kc/4n'rrl r n 1,7G;K frla�t 3 <br /> Signed X r _ <br /> Title: �C --X�� 1(�,� _ Data: <br /> — ---- — FOR DEPARTMENT USE ONLY <br /> Application Accaptod by Date <br /> Area <br /> Pit Or Grout Inspect by Date Final Inspection by Data <br /> Addi-•mal Comments: <br /> 0 5 168-6781 O Lodi 369.3621 ❑Manteca 823.7104 ❑Tracy 835.6355 <br /> `Appl`n-fit-Return all copies to:Environmental Health Parmit/Services 1601 E.Hazelton Ava.,P.O:Bax 2009,Stk.,CA 9520fFEE � <br /> y <br /> . INFO 'AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE CASH PERMIT'NO. <br /> tie <br /> - 17A tMFV.iiaer - <br />