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r' APPLICATION FOR PERMIT <br />SAN JOAQIJIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telepht (209)466 -Mi <br />PERMIT EXPIRES 1°YEAR FROM DATE ISSUED <br />(Complete in Toriplicate) - <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or lns"M the work herein described. Th* application s <br />made in compliance with San Joaquin Countv Ordinarua No. 50 for sewage or No, 1867 fat weAlpump and the Rules and Regulations of the S <br />Local Health District. 1 an Joaquin <br />Job Address ��..._.� lV ti j�cit <br />> " rY tat Size Pty. <br />ms's Narne q4 <br />} Phone <br />Cantraclot t L1t ertae <br />TYPE OF WELL/PUMP; <br />PUMP INSTALLATM E3 SYSTEM REPAIR q OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC -TANK SEWER LINES DISPOSAL Fi D PROP. LINE <br />FOUNOATrON AGRICIJLTUi9 WELL _ .' _ OTHER WELL _.�, PfTSatBi3UM <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP'ECtFICA nONS � ``�• <br />n Industrials 0 {7par! Butfcln4 ici pbi o1 fiAlfelt\ <br />0 Dom/Prlvlua ©� Eft�iru, _ Dia. of VI/eH casing <br />Try ypa of C Specification* <br />17, Public C 7 Other %i Dtha ' Depth of Grout Seal _ T <br />I I litigation _ � � ��_.- ...,._.._ <br />_.. �.. <br />..,,...YApprox, t34pdt 1! Eastern Surfawra Stwl Instaikuf by <br />Repair W" Done 0, Type of Pump H.P. _ _........ State Work <br />well O"tructionwee" Diameter sea Material (top W1 <br />th Fier Mef&W 113eiow 6fl l <br />instatt Wnn will serve:, Rrrsiiiarice y Cortattetciaf _ O o� <br />Number of ti units: . <br />"'n9 _ Number Of htdtrsotrts <br />chameter of sod to a depth of 3 teat; <br />SEPTIC TANK,,,, „l; -Type/Mfg Copan <br />PKG. TREATMENT PLT. C3 <br />Distance to nearest: Wall Foundation <br />ahrstur» perrrrntad it public ttVAW it <br />within �b few. f <br />Water table depth _ <br />No. compartments <br />Method of Disposal <br />Property Lint <br />LEACHING LINE i No. i; Le _ <br />+arF <br />FILTER 9E0 Total tengthlsizu <br />C] flistance to »: U4tael6P <br />Property Lktt <br />SEEPAGE PITS t') <br />SUMPS ` 0 <br />DISPDSAi. PONDS r l <br />papth <br />CJ rtott to naeow. V40FoundationProfftrty Lim _ <br />1 _ <br />I hereby certify that I have prepared this apPkatioy and that the work wail be done in acewdance with Son Joaquin county ordinances, <br />rules and regulations of the San Joaquin Lout Health 04ttiet. stats laws, sod <br />Home owner or /leaned agent's Signalise egntlfnas ft tajlowjn9: 'j certify that in the <br />employ arty person in such rrnannar as to bacortte sins" to wotkman's ptrfomsirtre'of the Mor tot vas h Otis Pam* is issued. I not <br />cer W** the following: "I certify that in the Compensation > of a ' I stia." Contractor's hiring or atria � signature <br />tion laws of California.,* performance the work for why this permit kt lsstsad. I shag errrptoy peraomt subject to -Ott San's corrtptnsa- <br />The appnt rt td 'nt t omplate drawkig rtvtrta . <br />Signed x 7�_ <br />14 01PA=Uj&j" O*Ly <br />Application A� by <br />' Daitr � <br />Pit Of Carrttrt i+tspactiort by .' <br />Data Final Inagisoftn by t3trtt r•-1 7 <br />Additional Commentt: r <br />0 Stk 46 4MI fl Lodi 3MW3631 C1 Aaiariteear B2�-ttb4 ❑ Tracy <br />Appkant - Retum a6 copies to: Environirrerzatd ' <br />Health Parmtl/S*rictar '1 M E. Ha=alton Ave.. P.O. Box 2009, S*_ Cit NMI <br />�,. , <br />1H 13-24 MEV, i a <br />Era I*m <br />