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APPLICATION FOR PERMIT <br /> � SAN JOAQUlN LOCAL HEALTH DISTRICT <br /> r ' <br /> ct71 E. HAZEL70N AVE., STOCKTON, CA <br /> Teieonone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Comoiete in T riolicatel <br /> AODIiCation is heiecy made to the San Joaquin L_cai Health District for a permit to construct and/or install the worx herein described. This dooiication it <br /> made in compliance whin San Joaquin CountV Ur, njnce No. -3 for sewage or No. 1862 for wedrpumo and the Rules and Regulations of the San Joaquir <br /> LUCdi Hedltrl District. <br /> Ir Joo Address •n �� j rJ(�� +�Q+ �1 t.'.0 Citv Lot Size r ! �M <br /> Owner s Nameu-V r' ( L I S �u address PC . L'X C I phone �!5�7 f�"/'lrc` <br /> a �,�I �rc+fe� � <br /> Contractor 7V�!►ef Eipl0t�rhf }_i.L1�( -__:ess -1i prelevrs{`_ygs`]safZ License No, i, � �0 Phone fll - 3 <br /> TYPE OF WELLlPUMP-. NEW WEL!11;1- 'NELL REPLACEMENT a DESTRUCTION ❑ <br /> PUMP INSTALLAT;C.] SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 60 DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL OROBLEM AREA CONSTRUCTION SPECIFICATIONS C,Kt, 41*t V 6✓1 S) <br /> Industrial Open Bottom - Manteca Dia. of Well Excavation pia. of Well Casing <br /> Domestic/Private Gravel Pack: Tracy Type of Casing 4�JL-- Specifications <br /> Pubfic 0 QGWdi4D0A Other Delta Depth of Grout Seal Type of GrPu1 <br /> Irrigation r3Lt' Aoprox. Deoih Eastern Surface Seal Installed by .tl„-u e";4A 1.9f t.l.nc-- <br /> f Repair Work Done Type of Pump . H.P, State Work Done _ <br /> i! Well Destruction Well Diameter Seating Material Itop 50'1 <br /> Depth Filler Material [Below 50.4 1 <br /> F SEPTIC WORK: NEW INSTALLATION i i REPAIRIADOITION 1 i DESTRUCTION I I INo Sepik system permitted it public sews <br /> available within 200 feet.l <br /> Installation will Residence_ Commercial__._ Other <br /> Number of living units: umber of bedrooms <br /> Character of soil to a depth of 3 feet: or[able depth <br /> SEPTIC TANK 0, Typaimfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. p is Method of Disposal <br /> Distance to nearest. Wed ation Property Line <br /> LEACHING LINE ❑ No. ti Length of Ines /size <br /> ALTER Bleb ❑ Distance to WON Foundation P me <br /> SEEPAGE PITSDepth Size Number <br /> SUMPS f.1 : Distance to nearest: Well Foundation Property Line <br /> SAL PONDS 71 <br /> I hereby certify that I have prepared this appiicaoan and that the work will be done in accordance with San Joaquin county ordinances,state laws, Ir. <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature cerofiss the following: "I certify that in the performance of the work for which this porn*is issued. I shall nr <br /> employ any person in such manner as to become subject to workman's compensation laws of California.”Contractor's hiring or sub-contracting signatui <br /> certifies the following: "I certify that in the performance of the work tar which this permit is issued.I shall ampfoy persons subject to workman's compens: <br /> tion laws of California." <br /> The aRpGcanI list call for all required inspillr-n . Complete dr ing an reverse side. <br /> Signed x '' i s --'x�' itle�: �O�G f, �— Dato: 2S[l_ h7 <br /> %j <br /> FOR DEPARTMENT USE ONLY L G <br /> �,t! <br /> Application Accepted by n+ Date �.LIf li� Area ' <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> k O Stk 466-67M1 ❑ Lodi 369.3621 7� Manteca 823-7104 ❑ Tracy 83544 <br /> r � <br /> Applicant - Return all copies to: Environmental stealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK s RECEIVED BY TE PER1NiT'ryty- <br /> I INFO CASH �} /� �►+� <br /> • EH 1324 IREV. <br /> EH 14.20 " t� i <br />