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AF'OUCATION FOR PERMIT <br /> SAV rOAQUIN LOCAL HLALTH DISTRICT �yY O <br /> 16 E <br /> HAZTON AVE., STOCKTON, CA D u u l��l <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUL I 9 ° <br /> (Complete in Triplicate) C H TM <br /> .by made to the San Joaquin Local Health Distract for a permit to construct and/or IrtatA tt &S �/OMOMOe i <br /> n with San Joaourn Count;Ordmance Nn.549 for sewage or No. 1862 for wef/purnp and 1119slim quLr <br /> city La Sim PM <br /> t Name �f`�-fie I�.� ete�1 �d ^�S/ 7arPhorw e <br /> . .•,, i,r �.C.�(.�.� _ <br /> Ado ress-`�' • �-� +'L+e'� License P-III; � <br /> :if OF VYFLL/PUMP NFW WELL WELL REPLACEMENT O DESTRUCTION O <br /> PUMP INSTALLATION SYSTEM REPAIR Q OTHER O <br /> '),TANCE TO NEAREST: SEPTIC TANK SEW[R LINES DISPOSAL FLP. PROF. UNE <br /> FOUNDATION _ AGRICULTURE WELL __ OTHER WELL PRS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industnsf O Open Bottom O Manteca Dia.of Wee Excavation _ Dia.of We/Casing <br /> /bomesnc/Private O Gravel Pack 17 Tracy Type of Casing_ SpadlltMWrld <br /> Puhlrc F-1 Other Fl Dema Depth of Grout Seal Typo of Orad <br /> IrrrgatWn Approve. Dwth I ! Easte+n Surface Seal Iad by ' <br /> 77 <br /> ne rr Work Done f e T , <br /> Pa Type of Pump H P. State Work Oar i1 <br /> Well Destruction Ll Wse Diameter Sealing Matarur(top W) <br /> Depth.__ _ __ Fftr Material(Below fig') <br /> T1111 i'F SF DTIC WORK. NEW INSTALLATION.' I RFDAIR/ADDITION I I DESTRUCTION 1 I (No asplip/yalam p�llNll�d M pybee www Is u+E <br /> even"ssMltie 7d=i <br /> Installation will serve: Residence— Cornrrrercial _ Othm <br /> s <br /> Number of Irvrtg units. ___ Number of bedrooms_ <br /> b' <br /> Character of soil to a depth of 3 feet: WMw 20M bplh r <br /> SEPTIC TANK Cl Type/Mfg Capadly No.CoetpwMMrrlf <br /> PKG TREATMENT PLT.Ll hidrod of mooed <br /> -_-- - --- Distance to nearest: — Foundation Property Lkw '7: <br /> LEACHING LINE F1 No. A LergM of Total Wglh/fine <br /> FILTER BED+ 1.1 Distance to rest: Well _ Founds Pro"ty Line <br /> SEEPAGE PITS I I Depth Size <br /> f - <br /> SUMPS I I Distance to nearew: Wes— Foundation Proparty Lim /} ] <br /> DISPOSAL PONDS (l <br /> I hereby certify that I have prepared this applkallon and that the work wN be dare in aetartkarroa twilh San,►eagtrin costly eraIwrefa,Mala NIM,sura <br /> rubs and regulations of the San Joaquin Local Nos"Ddtrict. <br /> Horne owner or licensed agent's signature cwtifias the folowmg: '1 coo efy that in"polo incl of tha work for wFtkA 000 It r bfalaA.1 aha/no a, <br /> employ any person in such manner as t3 become subpct to workman's compenwion In"of cawade."conMWwo hMlp of sovoweaft ttfprlMA w± , <br /> certifies the following: "I certify that in the performance of the-.w-wk for which this per pit Is bowed.1" <br /> antpby OMforn ttlr6laet/e workrtlwt'f oanperta♦ w <br /> i in laws of California." <br /> The applicant cat calf for air reqGuired inspections. Complete drswing <br /> I 5? <br /> Signed X Oahe: <br /> ofPARTIMENT USE ONLY <br /> Am <br /> Applicetion Accepted by -� ` /�%, /`J�r`t l L Dela 'r <br /> P!t or Grout Inspection by Date_ Final ktepeotft by DIM 4� <br /> Adlitional Comments: y <br /> SA 4666781 O Lodi 388.3821 I7 Manteca e23-210/ O Tracy 8354831111111 tN. <br /> A-)pkant - Return all copies to: Envimnnvntal Health Permit/Servicae 1001 E. HaaahOn Ave.,P.O.eml 2,$1k.CA IIW ' <br /> r <br /> FEE INFO AMOUNT DUE AMOUNT 11EMITTEO <br /> ICASH well D my DATI PeMMT'fap. <br /> A.. , . <br /> r <br /> ,T <br />