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/'\VI t (CATION FOR PERMIT <br /> - j.4 LOCAL HEALTH DISTRICT <br /> 1601 E HA%ELTON AVE., STOCKTON, CA <br /> Telepl-nne 12091 466 t1)81 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Apphcahon IS II!4chy Marie to the San Joaquin Local Health District for a IMrmit to crvesttuct andrur x:nn the work herrn descI4wd Th s application Is <br /> nwde In comoonco with Sen.Ioagmn Cnuaty Ordinance Ni.A9 Tor xe..adle or No. IW-2 for urea/pump and the R"las"Reg-rtat"w"of th"San Juoqu" <br /> Local Health District. ]� <br /> Job Address _._ <br /> —_7_s_.5- N. t 1 W J __ CdV ?.wDb lot Sire _ PM - <br /> ��� ` r L dress -- -._ — - ph011e ---- <br /> Owner's Name , 1EEJ� -- -- <br /> Ad <br /> Conti actor W--_ N- AACress No. <br /> TYPE OF WELLIPI-IMPNEW WELL I 1 WELL REPLACEMENT I i NEST' V%3N_l.-- <br /> -- nUMP INSTALLATION C; SYSTEM REPAIR I! OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _- ___. DISPOSAL flD.. <br /> PRM. LINE <br /> FOUNDATION -_ AGRICULTURE WF _ --_-cry-I ;-R WELL - /CTS/SUMPS — <br /> INTENDFD USI _ IYPE OF WELL PROBLEM AREA CONSTRUCT17.1 St -MOMS of WeM req <br /> LI Industrial - I I Open Bottom l i Manteca `y a Wen l `v <br /> • atton _ <br /> I 1 Donne-. 'Private I1 Gravel Pack l 1 Tracy <br /> as <br /> 'vPe or l 'np -_ _ _ Spec+facaelort" <br /> I'I Public I 1 Other I Doha Depth of Grout Type of Grcx t = --- <br /> 1 I Inglatlon -- Approx. Depth I ! Easlwn Surface S..W Instesed by — <br /> H.P. StaN Wlerla Oorfe <br /> Rep:.ir Work Done ! ' Type of PUMPwell Destruction I' Well Diameter -._--_ _ Sealing Material Itop 501 - <br /> Depth - <br /> E&"Material(Below 50') <br /> ------ —_- <br /> iYpE OF Sl, TIC WORK. NEW INSTALLATION, 1"-'AIA/ADDITION: TRUCTION I I IND O POC sYslera Psim"'nd a/�'r www• <br /> awlta0aa"1 200%0.1 �1 ww <br /> Installation will serve: Residence_-- Commercial Other— N, <br /> Number of Irving units: .-- _ Number of bedrooms_ kA <br /> Wates ratio darn - _ -.._--- - ----- <br /> Character of sod to a depth of 3 feet: - <br /> SEPTIC TANK [I Type'Mfd _ _- Cawlty_ No ComParl"Wels <br /> Method of Disposal <br /> PKG. TREATMFYT PLT.11 <br /> Distance to nearest: Well _- Foundallun - . -. -- _ Propenr Lyle -_--_-- <br /> I EACHING UNE I 1 No. B Length of Fnes <br /> FILTcl`t BcD I Distance to nearest: Well -. Foundation___-- _-- Pt,4wW Lite <br /> SEEPAGE PITSSit" <br /> SUMPS I I Distance to nearest Well Foundation - Prop"lw �j�;' <br /> DISPOSAL PONDS I ! <br /> Aft-� /fid Lit09 <br /> 1 hereby cnrtlfy that 1 have pteparerl this application and that IIIc work WIN be dune In accordance MMI'Jan Jnagu'n r r bot nan+aa. state Iaws, wvf 04 <br /> rulas and rogulabons of the San Joaquin Luca)Health DIVIict rrot N m!Iwd. 1 shall not <br /> Horne owner of hronsed agent's signature certifies the foanwmng: "I certify that en the p rtiol lanC" " <br /> Of the w .k rur'1 this per <br /> employ any person in such rrsnnar as to bacon"sublecl to workman's compensation 164,of Cohforrw-C �.n!a nwlnp tr wA c<venacr•ng srgnatur► <br /> esniflas the following."I certify that in the performance of IM work for which this p f"I is asued.I shad` '''•w t of k)ns subOKt to wo'km.en's con*Iw U <br /> Vats <br /> "f-PPI-CO." <br /> nl Cahfrnn ' <br /> The apphcal t cell all ��ltL_ nxper <br /> ��to drawing on r`ssrse ud <br /> Sig <br /> TrOo <br /> FOR DEPARTMENT I'-;IF ONLY <br /> ACr <br /> AP4lication AcraprwA hY L��Q� - Date-jl- -�-i-- A•� - <br /> /1,t ' / <br /> it r Grout Inxper bon by .'t/ri�t 1 ,VA, _7i_7 G Final rnspectww Or f <br /> Add iional Cominenis -C4.4-7 <br /> CLGZ•as�CrA- -' ___ <br /> I I Stk 566791 1 1 Lodi 3693821 .J ptoMan- Ail��118111 F. NTracy <br /> Awa O. eat 200", Sri. :A>1�0f <br /> Applicant Return all copes w- Environmental HOW*. <br /> ffE AMOUNT tItJCAMOt1NT PFMIRCO� CA�ef -rtECilrrc0 By prIT1 PIR— t t� <br /> (NFA - -------,----' <br />