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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES_I YEAR FROM DATE ISSUED <br /> lCompiale in Triplicatni <br /> Aptd,eat,e+,,s hr why n,nne to the San Joaquin Local Health DistrrrI for a permit to construct andlor,nstalt the work herein described. This 8001c4hnn n <br /> ,made,n cnmphdnrr woty Sdn.i4ijo "n Cniinty O,d,nancu No 'r49 lei sewage of No. IM2 for welllpump and the Rules and Re{lulaiions of the San Joxtuifi <br /> Local Health <br /> Sob Address . City , List Sire _.I—�G.�- PQM <br /> Owner's Name Address - <br /> Phone 44PS <br /> Contractor)OJDKJEt4 4 572DC Address License Nof� S7--_Fraise <br /> TYPE OF WELUPUMP; NEW WELL " \GR <br /> ELL REPLACEMENT 0 DESTRUCT'ON Lr <br /> - PUMP INSTALLATION L1SYSTEM REPAIR Ll OYHER.0 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ LINES rDISPOSAL FLO -- PROP, LINEFOUNDATION _ _ LTURE WELLOTHER WELL_ PITSfSUMPS <br /> INTENDED USE TYPE QF WELL PROBCONSTRUCTIONSPECIFICATIQNS_L� Open Bottom i i MaDia. of WExesystran T _— Qia.of WON C&WVDomiWiclPrivate 1.1 Gravel Peck I i TtdType ofE..� P,il'>Iit ! 1 O11tPr IltDepth of{irout SealType of GroutApp,oa. Depth I l Eaelate Seat Installed byRepair Work Done 1 1 Type of Pump --_ —. __ -- State Wort[DomWeN Destruction I I Well Diameter _--- g Mate 1 Itop 50'1Depth Material Blow 501 <br /> TYPE OF SEPTIC WORr. NEW INSTALLATION REPAIR'ADDITION I I DESTRUCTION i I INo septic system permitted if public Bawer to <br /> ,/ available with-700 feet.) <br /> w `! <br /> nt <br /> 3 Installation <br /> ill serve: heaidence— Cornercial Other_ — <br />( Number of living units: ._, Number of bedrooms — <br /> li Character of soil to a depth of 3 feel: Water I"depth <br /> t _ Capaeily�No. Compartments _— <br /> SE C TANK C7 TypelM}ry�—......_.__ <br /> 'KG. ATMVNT PLT.I;1 Method of Disposal <br /> Distance to nearest: well_._ Foundation Property Line_ <br /> C)I(- <br /> 15—tow-D <br /> LEACHING LINE 11 No. &Length of fines Total kngthlsire_�--. <br /> FILTER BED [ I Distance to nearest: Well _ Foundation Property Lina — <br /> SEEPAGE PITS-^` I 1 Depth __ 51ri���' ..A-.3 Number Yt+'Ft <br /> SUMPS I Custance to nearest: Well Foundation — Ptopatty Line <br /> DISPOSAL PONDS I <br /> I hereby Ce"i'y that I have prei-,ad this application arid'lhat the work will be done in accordance with San Joaquin county ordinances, stats laws. arw <br /> rules and regulations of tit. oan Joaquin Local Health District <br /> Home owner or licenser'agent's signature cartifis*the following: "I certify that in the performance of the work for which this permit is isuwd, I Shan not <br /> employ any person,n,uch manner as to become,subject to workman's compensation laws of California."Conttsctot's hiring a suDcontrsctinp signature <br /> certifies the followir,t:"I certify that in the performance of The work for which this permit is issued.I shall employ persons subject to workman'$compensa <br /> tion taws of Califor iia." <br /> The appt,c mr .can for all required inspections. Complete drawing on reverse sidle. , <br /> Signed X. if v` Title; -= 'F, <br /> FOR DEPARTMENT USE ONLY U ;, <br />�? Date 'Sa-- Arae <br /> gg' Application Accepted by -- J rtaa ee <br /> Onto <br /> Pit <br /> - Lis Ell <br /> Pit"fGrout Inspection Date Final Inspection by <br /> Additional Comments: . -- �^ <br /> is i Slit .66.6781 ❑ Lodi 369-3621 ❑ Manteca 8217104 C7 Tracy 835-63815 <br /> Appe <br /> Applicant Return all cople to: Environmental Hoelth PermitlService$ 1601 E. HataHon Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DU! AMOUNT t1EMIT'IED f 11ECEIVEp By DATE PI ItM17N0 <br /> tNi 0 <br /> FN rd>t <br />