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<br /> APPLICATION FOR PERMIT
<br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT "p
<br /> 1601 E. HAZUL T ON AVE., STOCKTON, CA ,.
<br /> TeleptlDre (209) 466-6761
<br /> fxkPERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;
<br /> }ie (Complete in Triplicate)
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<br /> sl + Application is he eby made to the San Joaquin Local Health District for a permit to construct and/or instal!the work herein described:This epplrcatlon(s
<br /> ,t 31`r r1. oaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules end Regulations-oi the Sint Jomjin
<br /> ;•�, � .made in compliance with San J K -
<br /> T r� Local Hsafth District. :. -0.
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<br /> Ch �I I� LotSeJob Address _�'. Q C�/t ESM•-
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<br /> Owner's Name'_ 1� Addrtrss a�l� _ J t r r-t w A4eL c//fe no
<br /> Imo,yI ei".r• .1 - .-:. .. r7� :_• ., - � �„ ...: .4_<- y yY'r,{�'•i'r,'�,'Y.,, ,-
<br /> .Cwtracto _, /!! � Address Lirense-No Ph'ine , F
<br /> �} "t TYPE OF WELLlPUMP: NEW Wc,:. L7 WELL REPLACEMENT ❑ DESTRUCTION ❑ } fi
<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ aK"' OTHER
<br /> Clk
<br /> DISTANCE.70 NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. ROP
<br /> r" l 2.
<br /> FOVfJDATION AGRICULTURE WELL OTHER WELL PITSl5UMPS
<br /> fry .+ ,
<br /> i INIENDZD USE TYPE OF WELL-,:' PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> Industrial Q Open Bortom p' ❑Manteca Dis.of Walt Excavation Dia of Wati Caving ` " s
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<br /> ".3 '•r - ❑ DomesticlPrivate ❑ Gravel Pack ❑Tracy - Type of Casing Spec�fieatloitsr+p71
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<br /> ;' ❑ Publ c G Other ❑Della Depth of Grout Seal Type of Grout
<br /> ,;, I7 Wig H.
<br /> __Wox DeplO', ❑Eastern" Surface Seal Installed by-
<br /> L
<br /> r_ RMa;i,Wak Done ❑ Type of Pump " N.P.-- State Work Done a�t xfi(-,
<br /> r Sealin Material[top 50) w
<br /> WPIi Destruction TJ Well Diameter
<br /> S
<br /> Depth `^ Filler Material IBeI
<br /> :.TYPE OF SEPTIC WORK: NEW INSTALLATION "REPAIR! DITION . DESTRUCTION I� 1 N septic system permitted if:Publc'eewer
<br /> L .:' ,- ilable within 200.E .)
<br /> fi{ ; Instailatlon will serve:,'Residence Commercial�. Other f
<br /> rr. r m living units: '"Number of bedrooms= / ' ;3y r4 x+ ` f i
<br /> Number of � �• .. '� .•'
<br /> o x z ry. x Watertabfe:depth o=tis '' J I
<br /> Character of so+T to a depth of 3:set
<br /> SEPTIC,TANK•:•;'.- ❑ Type1Mfg Capacity ,No,-Compartments - 3V'3'WIN .J �
<br /> 1 i ' 2 ,Y
<br /> PKG TREATMENT PLT.❑ <, ° k Method of Deposal, r• I
<br /> 1
<br /> ✓y /r't > ,s ti Dir once to nearest Well Foundation r Property Ltne `�`
<br /> h, a �; [ p "-,Total Ylength/size f'
<br /> LEACHING LINE,- i No.8 Length of,lines �� erik
<br /> 1Veil r' Foundauan_ Property Late " .f`s `
<br /> FILTER BED, ❑• Distance to nearest:
<br /> �w r
<br /> 'a Da th Z.J 4_'Size Number)
<br /> SEEPAGE PETS -
<br /> (`a"?, ` Wall Foundation Property Lire
<br /> SUMPS- n Distance to ne?r"t•'• �1
<br /> -1 •, s '� '..,+�. ', -` �"!• •:� ''.�',�t-t•�- ' cA�fis�.•��:�+�`�rtk.i�' f`'
<br /> DISPOSAL PONDS [] °0 laws.artdr". I
<br /> 7� " ;1 hereby certify that I have prepared tnK appiicatiion and that the work will be done in accordance with San Joaquin county wdinan a
<br /> ;.]4,,i'7'��•�5 i �;: rules and regulations of the San Joaquin Local Health District. . ' w ," ` r'�,I." '"..r.- ljis- er +.
<br /> ' �? , }.. ringL
<br /> }{oma owner a Geensad agent's signature cert?les the follow ng:"1 certify that in the performance of the work for`whieh'this parrrst is issuers I shelf nate
<br /> N'
<br /> 'e-pty any Person in yich manner as to become:trbjerci to'-vorkman'a cpmpertsat on taws of California.' Contractors s or ct tstrb t acbnp
<br /> certifies the following:"I certify that in the performance of the work for which this pee mit is itsUed.I Shall employ person t ! y
<br /> xr5�-.4 tion taws of California. `
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<br /> ' The aPpfcant mu calf for all roquir d inspections.Com4Jete dra%,Ang'on reverse side•
<br /> + -4c_�» Title: ry r q c1 is —4r-
<br /> 311
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<br /> Sighed X_
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<br /> F� 'OR DEPARTMENT USE ONLY: •� '� G�iY ,.'t.-• x�,; ls T .
<br /> �t. Date J Q b Area
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<br /> AppJicatton Atcepred by — - -—••' -"+'�`4 rZ`t ,�
<br /> �zfY t< r - 2-7,SL 'Date
<br /> Dare Final Inspaetron by a e
<br /> /` Pt or Grout Inspectson bV
<br /> y{'.,AY� -� - Addaional Com-marts: ❑ Lodi 369 3G21 .-_" Marteca 82;3-7t00 -_'❑Tracy-`835
<br /> s sM`[ff ❑ Stk 4F{-6MI
<br /> z i Appl;cant. Rewm all•copies to: Environmental Health Per
<br /> 1501E Hazelton Ave P;O Ba:2009 Stk rCA 96201 *�r`� u 1
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<br /> CK r RECEIVED BY:'!•. DATE '`:" .PEAMiT NO'";
<br /> eft •� c AMOUNT REMITTED - =>� K s', -
<br /> r - tNE� AMOUNT DUE - ` CASH M .`
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