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• APPLICATION FOR AIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made a the San Joaqu�o Local Health District for a permit to construct and/Or install the work herein described .'Ms application is <br /> .,,,Is in cI mpbara.with San.Inunain County Lid mancu No.549 for sewage m No. m2 for wall/pump and the Rules and Rsgulatinna 'f rho Sen Joaquin <br /> Local Health District. <br /> � S�s�µ <br /> J[•:.Addeess -__kX�.-/^-��� —/IY�J��r'= City k,MWAk-Lnt Sive_ y/( PPM <br /> Q <br /> Owner's Name_t/�,V�s �s �. Q_�P�hyoria S,'2/6,2 <br /> TYPE <br /> C <br /> Contractor_A r�/.A1 FdGc:—Address (Ss�y_GZLZF U/rJ�License No,��JJJ_L Phone oY9}- <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C DESTRUCTION C <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C <br /> DISTANCE TO NEAREST:.SEPTIC TANK _— SEWER LINES _. DISPOSAL FLD.__ PROP.LINE —_ <br /> FOUNDATION AGRICULTURE WELL ___ OTHER WEl PITS_ <br /> /SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial LI Open Bottom ❑Manteca Die.of Well Escavation Dia.of Well Caring __- <br /> 0 Domestic/Private CI Gravel Pack C Tracy Type of Casing_ Specifications <br /> rl <br /> III Public fl DIM1er FI Delta Depth of Grout Seal __ Type of Graul_____._. <br /> 'I 'Initiation .__Approx. Depth I 1 Eastern Surface Seal Installed by it J <br /> Repair Work Done I) Type of Pump ____ H.P.___-- State Work Don._ G� <br /> Well Destruction O Well Diameter Scaling Material Trop 54"9 — --- -- V'1 <br /> Depth_ Filler Material(Below 50) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 available trw thin 2170 laatsystem rl)ad i1 public suwvr is <br /> Installation will serve: Residence_x Commercial_ the,___._—. <br /> rK <br /> 1 Number of living units:L_ Number of bedrooms <br /> Character of soil to a depth of 3 lees A Irnf1 Water table depth <br /> i btPTIC TANK C Type/Mfg _—CaPacitvJ,a r-"' Method of of Direnn <br /> i PKG. TREATMENT PLT.C Metisposaf <br /> Distance to nearest: Well <br /> Foundation Property Line L� <br /> LEACHING LINE 't No.&Length of�lines 7 Tatsl hngth/size__p.�f__ <br /> FILTER BED Li Distance m nearest: WeII_ Foundation__ Property Lina_•+ .. v <br /> SEEPAGE PITS I I Depth __Size_._ Number <br /> .� SUMPS LI Distance to nearest: Well Foundation—__ Property Line <br /> DISPOSAL PONDS 11 <br /> 1 hereby candy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or lic ursed agent's signature canities the following:"I certify that in the 0.performance the work for which this permit i11 Touting 1 shall not <br /> ure <br /> employ any person in such manner as to become subject to workman's compensation levo of California."rn1Contractor's hiring or sub-contracting meanies <br /> conifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persona subject to workman's companies <br /> " tion laws of Coif.mia."v <br /> 1 The applicant must call for all requir d inspections.Compilers drawing on reverse side. <br /> X <br /> / eaj2/ !////yi.r(, _'Z_/- Title:_ l G(� D"9: <br /> Signed --�S"�= _ <br /> � ) FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dele <br /> Pit or Grout Inspection 4, Date Final InsWctlon by <br /> Additional Comments: <br /> C Stk 4666761 C Lodi 369 3621 C Mantes 1123-7104 C Tracy 835-6395 <br /> Applicant-Return all copies to:Environmental Health Permit/Services 1601 E. Haxalton Ave.,P.O.Box 2009, Sik., CA 95201 <br /> 7F!q <br /> DUE AMOUNT REMITTED ASH RECEIVED BY PERMIT NO. <br /> . En 13 N[REV.rrxal o � -�� -183 <br /> H 14$11 <br />