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APPLICATION( FOR PERMIT <br /> SAN 'OAQUIN LOCAL HEALTH DISTRICT <br /> 16601 E. HAZELTON AVE., STOCKTON, CA <br /> Telsootie (209) 466-Ml <br /> PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED <br /> (Complete in Tnoicete) <br /> Application is h rehv m.do to the Sen Juaquin Local Health District for a permit to construct and/or 1taM the work fmob dea:rbed.This applkatim is <br /> made in r.niphance nith Sen.Joaquin County Ordinance No.519 for wvj p or No.1P92 fur wall/pump and tins Rubs and Regulations of the San Joaquin <br /> Local Hearth Mstrict. LO T 13QUJK <br /> PM -7072- <br /> Job Addreaa _3 `! O f�-' �Cia7 L���„ sL <br /> / GO ddr md 3 U �t F,� F ho <br /> Owner's Nam-, �L/�a <br /> Cor ,cta �EddA resp_ ' `Icense No. <br /> TYPE OF W LL/PUMP: NEW WELL ❑ WELL EPLACEMENT ElDESTI;UCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWFF, LINES DISPOSAL FLD. PROP. LINE <br /> FOUNCATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS v <br /> INTENDED USE TYPE_OF WELL PROBLEM AREA CONSTRUCTION S.'ECIFI`JITIUNS <br /> ❑irtdtratrbl ❑Ope t Bottom ❑ Maraca Dia.of Wall Excavation Dia.M Wall CaeM11t <br /> O Domestic/Private ❑ Gravel Pack ❑Tracy Type of Cnktg__.. Co^s 1 <br /> i <br /> ❑ Public 0 Otter ❑ Doha Depth of Grout Seth Typo of Grout <br /> ❑Irtipatb.•n —Approx. Depth L)Fasten Surfaoa Seth Irstsllcd by <br /> Repair Work Done ❑ Type of Pump H.P. St to Work Oona <br /> Wal Demruc:ion <br /> 13Well Diameter _ Seeing Matt w Itap 60') S �^CIA - <br /> Dopth_ _ Filar Msty Wallow 601 <br /> TYP OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION❑ INu septic system parr e If pubic sewer Is <br /> E awlehM within 206 het l� <br /> 4 lnserttion will serve: Reeldence— Commercial— Other <br /> Number of IMng units: Number of bedrooms_ <br /> Chsra^.ter of sol to a depth of 3 feet: Wow t"logit <br /> SEPTIC TANK ❑ Type/Mfg CqW" No. <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: We" Fou nds*n — Property Line <br /> LEACHING LINE C1 No. b Length of lines __. Total l ngth/sirs <br /> FILTER BED ❑ Dietence to neatest Vral_ Foundation---- Prop"Line -- <br /> SEEPAGE PITS ❑ Depth ---SIR* _ Number <br /> buMPS ❑ Dbttxnce to nearest: Woo_ Foundation Prtpaty Lis <br /> DISPOSAL`ONDS ❑ <br /> I hereby osrlfy that I have prepared this application and that Iha work wl!be done In accordance with San Joaquin county ordisnow,r-r awe.and <br /> rules and wJu4tions of the San Joaquin Local Health District, of the work for which this permit b bested,t shall not <br /> Hone owns or Ikw»ed egam's signature cartHies the following: cenlfy that In tie performance <br /> 4 employ sr,­parson In ouch manner w to become subject to wotkmsn's compensetl n laws of California."Comrector's hMng Or arb•comn ctkq signature <br /> oertrllee the rcaowing:"I certify that M the performance of the work for whlch thla permit la al ImIed,1 Nemploy priors sub0ct to workman's compase- <br /> ' tion laws of California." <br /> r The spotkant muN-call for aN nquk•ad kse <br /> sp �01ts. l;:om We drawing an reverseJds- <br /> Signed X_� LI.Gfit.[i��-�JGGT�lL�slt Title: y - Date: <br /> / FOR DE►A ENT USE ONLY <br /> Date Area <br /> , _ <br /> AppleatK-n Accap:ad by - <br /> P%or Grout Inepectio.l by <br /> _ Deli Final InspaCllofl by D <br /> AddHbevlCoxnman s: <br /> ❑ Stk a0K 1 Lodi 5eai:11121 ❑Marttsca 923.7104 0 Tracy 8354 KMS <br /> Apparent- Return 011 c el to: EnvlIag m4"" „mit/Sorvioes IWI E. Han hon Ave., P.O. Box 2008, 3tk., CA 95201 <br /> rrEF AMOUNT DUE AMOUNT REMITTED AEC"O ey DATE ►ERMITNO. <br />- MFO <br /> 10 �y <br /> (Nr1a/falV.t,rer ��' �� ��• -v-X, Esso <br /> FM KM <br /> F <br />