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APPLICATION FOR PERMIT <br /> SAN JOACIUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZCLTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Apbilc3tton s hweby made TO the San ioaq;,in -ocai Hewth District for a permit to conStruc%a, <br /> nd;or install ttar <br /> the work bare doweanw.Ths applica <br /> nude in cornpiidnce with San Joaquin county Ordinance No.549 far sewage or Na.IBM to,*gjoump and the RuI"and Rtiguiatiorm of d*San Jcaq ;n <br /> Loca' Hez,;th 04anct. <br /> Lot -------- <br /> Jo-i A <br /> Owne'sNarr*. ....I --t— Addralss, <br /> Namw' <br /> TYPE OF WFI-LiPUMP. NEW WELL WELL RP-PLACEMENT 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR 12 <br /> DISTANCE TO NEAREST: SEPMC TANK SEWER LINES _ D45POSAL FLO- PROF.UNE <br /> FOUNDATION AGRI"LTURE WELL - OTW:R WELL PITS/SUMPS <br /> INTENDED "E T*PEor'wCLL' P.1108LEM A4+EA ONSTRUCTION SPEdIFICAT164S <br /> Dm. of <br /> 2 In&AMw, 0 ODOn SOMt <br /> M 0 Maroca Iola.of W&., Fycavation <br /> a, DrA-w"vft/P-1v;,w C GrwM Pack 0 Tracy T-j"of C",%; <br /> li T <br /> C Pubfic Cr loopth fitoGrout Seal lype 00 Grox�t— <br /> lli';race seal imult'd by­.......... <br /> R H.P. Ooft <br /> ArAir Work Done :2 TWe Cf Pump <br /> — we Diameter <br /> Sea6N Mlwtonal (rap W) <br /> Depth ......... Filler mabriai 48eiow 50'1 <br /> 4140ft 0 Pwic sewe <br /> -YPE Of SEF'rtC"RK: NEW INSTALLATION 0 REPAiP;ADDITON <br /> evoilabl6=01 MV) <br /> i <br /> ',,,umbw M Ung unft: Number**4Pdroorm t A <br /> c,netactair of*J to a depth of 3 feet: <br /> SU,'.IC TANK <br /> Method of Diwpc4al <br /> PKG. TAf <br /> -ATM ENT PLT. • <br /> Distance to rommat I~— Line <br /> ;LEACHING UNE Length or low Total langtbi# <br /> BED weli <br /> SEEPAGE PITS ✓ "'Sim Number <br /> SUMPS Z Ohtfsrtco to Z-'exasv JVVA Fourdaticr. Properw Line <br /> PONn- s (7 <br /> I hereby Certify the I hash prepared acc�,,dof;cti vvkh Son joacum as, vwa'aws' end <br /> .1118 aWf,_ation that the work will be done in 0?&Inisn' <br /> ,ulas and fieg zjU*iiom of the,Son JwukLocal Health 04grict. <br /> Home awnv or!icoimaed ag*t)t*s signature certifies this following: caeffy that in the pe-lon-nar.rb of ttA worlt for vA&.;ch th4 permit is dsLed, <br /> ac igns'"t <br /> IiKs --" <br /> or-14ACY arry pit"Sorl it,euc to vwKkma n'z C'Ornpon"- <br /> the tri rmante of she work fcr vvtucah this perm;!I$i4dj6d- <br /> that In <br /> "y <br /> The appiican cau for ail aqui ;r. ens. I✓ drawsr~p Jo�7�.J!•OY�rrb side, } <br /> FOR DEPARTMENT USE ONLY <br /> Data e?, 5'— <br /> w � - <br /> Appiican Accvtod by <br /> 2'-Da*e-flit-or-6mu*fnispoc-104)by--- <br /> Additional Commients: <br /> Stk 466-6781 0 Lodi WO-3621 C Manteca 823-7104 <br /> Appiic.ant - notum all oopim to: rinvirtiraviontw swihn Psrmit'Servicos 1S0' E- Ke2ftlton AVO., P.0- $0*206, Stk.,.,CA%Z <br /> "'OuNT ouf Amwt#T REIATTEo RECEwlim BY DATE PIERW,4m, <br /> EH !Ae.? .?w`0C1 A <br /> 04 wzb <br /> .......... <br />