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. �°, sw "1r�':�:�,- -J �i���..� 3_:is -aY-."r 7`c "•�s ��Y"o.� s�- a�3._ -r�'�"¢� �.�y'D}.�,7 ��;-'�' X-�oa -4'' -. '' �Ss' � .Sr.� <br /> .p r:.y-'�z'•"� s;,; t�...�"z�''*'� � .„is-: �; �..k �,ti� •.a` � �'�r4.`_: ,.+. r;�'_r.:�"��ne�.a-`. „�'"' "i�`.r�,::-6; ,;.�. � �R r�z`��r-��v.�i <br /> Fw 4 >st'.Y ^n+�' .$- 'i. �i�'�.lM Yr r±+.5 h '�w _;M1✓ x-.v.�'i?+i`�44.v.�fie.-�L;dp,_. .t; � <br /> a'- <br /> t - <br /> f�` <br /> APPLICATION FOR PERMIT <br /> SAP! JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.601 E. HAZEL ON AVE., STOCKTON, CA <br /> Telephone t2C91 40,&-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> n at <br /> ;pplica nor masrweo•ram San JGa OS,n County U groan ce i or for <br /> r arla,urtNn 1e;ii? of west Pumn anJ Inc H i!ns ansr'N r,.=u,atians or 1rno(S,Joaqu,n <br /> •,taoe,n <br /> L�CaI HeaRh District <br /> Lot Sire <br /> .,iib Aderess <br /> ...�_,'^..�r�• ., 1 r-_ ! r :if <br /> Phan. <br /> `S.!r . .l r' _ address <br /> Owner s Name try <br /> hti !!A!I•_a l�S <br /> Contractor 1 l <br /> f' ki . <br /> -Ilse <br /> tine <br /> NEW WELLRErrLAL'EftENT DESTRUCTION ,, �fJJpf/Z- <br /> TYPE OF WELL�PUMi': -L�� OTHER i. <br /> PUMP INSTALLATION i SYSTL"ftt REPAIR <br /> DISPOSAL FLD._ _r— TROP- LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINESPtT515Uh1P5 .� <br /> �C•T++i I'i r , <br /> FOUNDATION AGRICULTURE WELL ---OTHER WELL-.��---- <br /> INTENDED USE TYPE OF WELL '108LEPh AREA CON STRUCTIOtJ SPECIFICATIONS r' <br /> _ Dia.a1 Well Casing _ <br /> - Industnat Open Ronnm _: Manteca Dia,of Well Excavation�. <br /> _ Tracio casinc, Specifications <br /> OomesucrPnvate �{Gravei Pack <br /> Type of Grout _ <br /> Public Other Delta Depth of Grout Seal <br /> Ir�zgauon L(�Approx. Depth - Eastern Surface Seal Instalied by <br /> u r` .• - Typrs of r'umn State Work Dona <br /> Repan Work Dane' <br /> Well Destruction Well Diameter Sealing Material Itop 50'6 <br /> Depth _ Filter Material)Below 50'1 iz so <br /> TYPE OF SEPT WORK: NEW INSTALLATION: REPAI�!ON I-- DESTRUCTION LU �Nova;l eptic Sy able will �ez��cet fed if puhli sower rs <br /> z installation wil serve: n-e— Commercial �,—.--- <br /> rA Q mher of living units: Aru of bedrooms _ Water table depth <br /> ;q aractar of sod to a depth of 3 feet. No,Compartments <br /> wA T[C TANK ❑ TypHlMFg Capacity <br /> r� <br /> Method df Disposal <br /> TREATMENT PLT.❑ Property line <br /> Distance to nearest: Well ndarren - <br /> ! '; - tel lengthlsize <br /> t,] L CHING LINE No.&Length of lines <br /> ',] Distance to nearest: LN6I1 Fou ndatron <br /> try Una <br /> �� ER BED <br /> {`� w Number <br /> AGE PITS C3 <br /> Do. <br /> Size <br /> p PS ❑ Distance to naweet: Wall Foundation Property Line <br /> OSAL PONOS <br /> ahy t©reify that I have preparad this application and that the wan:will be done in accordance with San Joaquin county ordinances,state laws,and <br /> CJ ru s and regulations at the San Joaquin Local Health District. <br /> W Horne owner or licensed agent's signature certifies the following:"I caruty that in the performance of the work for which this parmit is issued,I shall not <br /> m rsons subject to workman's camtsensa• <br /> .� Homey any person in such rs+annar as td betamo sublet[to wo ttman'a compensation laws of Calitom a."Cnn[rectofs hiring or sutttokmaning signature, <br /> Z certtf es the following:"'I ceroty that in the performance of the work for which this permit is issued.I shalt employ Pe <br /> CAI <br /> tion laws of California." <br /> The APOCen must c for all r uir d ins�ans.L lmoleta rowing on reverses side. C <br /> /h'S1 r31,/`�` Date: <br /> Title: <br /> Signed X <br /> "R DEPARTMENT USE ONLY <br /> Do[tra Area <br /> Application Accepted by Date <br /> Dote _ Fiml lnspecuon by r <br /> Pit or Gfout Inspection by J2 I A�12 �•s•-'"- , G <br /> Addisioasl.CommHnts:_.� -- =`-Mort ---- .7[04------t Trac/-- ---------- -. <br /> 1 i�Stk 466-Ml ❑Lodi 3t'�-�W1 <br /> Appt=nt•Return all Cepias to:Environmemal Health Parmnl Servicers 1601 E.Haietton Awe., P.O.Sax 2009,Stk.,CA 9528 <br /> RECEIVED BY BATE PERMIT NO. <br /> FEE AMtlUNT D'JE AMOUNT RE%iJTTED _ <br /> IN PD <br /> .fes 1S741ltEw,­­L <br /> Eli t470 ._.. <br />