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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />'T ei%)horte(209) 466••6 <br />86. 1 MI <br />PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Compkft in Triplicate) <br />Application is hereby nuide to ttw San J08411rn Local Health District for a penytit to construct andlor install the work herein das&lmd. This application is <br />made in compliance with sa, josquin County ortfirence No. 549 for sewage at No, 1962 for WelIJPumP and the Rules arid Regulations of the San Joaquin <br />Local Health District; <br />PM <br />Job Addams. ......... city <br />Let Size<. <br />Phone <br />Owner's Name Address v <br />lor <br />TYPE OF WELLIPUMP: <br />NEW WELL C1 WELL REFLAA;tNIM I U Vw#---7 — <br />PUMP INSTALLATION 0 SYSTEM REPAIR 3 OTHER 0 <br />DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO— PROP. LINE <br />---FOUNOAT4ON--------AGR <br />LTA)REWEW,-=---- OTHER-WFLL- -P`lTS/SL*APS <br />INTENDED USE <br />TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Lj Tnd0;id;1 <br />6zp-S; Die. of Well Casing <br />i—Typit-of <br />n Public <br />C other Delta Depth of Grout S421 Type of Grout <br />0 Irrigation <br />-Approx. Depth n Eastern suyfe6�Seal Installed by <br />Stem Work Do" <br />Repair Work Dom 0, <br />- <br />Type of Pump <br />� <br />e- g. g MItef4i (top W) <br />Well Destruction <br />Weil Diameter <br />--EiIer Material tBelow STI <br />Fyn OF svnc WORK: NEW INSTALLATION 171 1 <br />installation will serve: Residence Commercial <br />Number of living units... -1____ Number of <br />Character of sail to 8 depth Of 3 fee <br />SEPTIC TANK D Type/Mfo <br />PKG, TREATMENT PLT, D, <br />Distarice to nsiarmic <br />LEACHING LINE) R11"No. <br />FILTER RED C-, ,Olifl <br />SEEPAGE PITS k4-Dapth <br />SUMPS f- Distance to nearest. <br />ndatit <br />t <br />"TION U (No septic SYSt— PsymKItc <br />16 available within 200 feet.) <br />t. <br />ev WSW table depth <br />No, Compait" nu <br />Method of Disposal <br />Property Una <br />71 — 3 L) _ Total lengthigm <br />won _,TD —! Foundation -- - ... Prop" Line <br />ilea �&�— --- Number <br />Wit —" Foundation Pmww Line <br />public at~ is <br />I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin county ordinances, state laws. arm <br />rules and regulations of the Son Joaquin Local Health District, <br />Home owner or licensed agent's signature certifies the foll&W". 111 certify that in the performance of the work for which this permit is issued, I shall not <br />employ any person in such manner as to becomesubject to workman's compensation laws of. California," Contractor's hiring or sub -contracting signature <br />certifies the following: **) certify that in the Performance of the VV01k for which this permit is issued, I shall employ persons subtest to workman's con"Pensa, <br />tion laws of California." <br />The Applicant reqSt call for M IreA inspections. conrl"te drawing on rove <br />""" "' ` I T) - 1(7 <br />U Z. <br />Signed X- Titlet <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by cow Area <br />Piz or Grout IrApection by Date Final Inspection by Dow <br />Additional Commenti. Ll 0 Tracy <br />Stk 466 -Ml 0 Lodi 3W3621- 13 Manteca 823-7104 1 E. Haialton Ave., P.O. Box 2009, Stk., CA 96201Applicant - Return all cools$ to: Environinentall Heatth Portnit)SOMACAS 160 <br />EH 1124 AM I � 6 <br />EN .26 <br />