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I`I <br /> ! i <br /> Y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT; PAYMENT <br /> 1TON AVE., STOCKTON, CA RECEIVED <br /> _V%L1Ct1�' OTy Telephone (209) 466.6' I DEC <br /> oA coom— LIV.N ' I XPIRES 7 YEAR FROM DATE ISSUED <br /> r <br /> xM �7 (Complete in Triplicate) _ I SAN JQAQUfN COUNTY <br /> PIJSLfC HE T '� <br /> Application e; •rrhyinade4o tnr San,loarimn Loral Health District for a permit to construct anti/or instate the work <br /> matte in comp rico wish C,­nty Orthnancn No.9A9 tot sewaile or No. T11f2 fur welllpump and the Rules and Regulations o <br /> Local Hedtth District. <br /> Job Address CityL. �tr of Site POA <br /> Owner's Nama P' _.J ! Address ��d �+.._L�__v.iJfl `-" w Gl!�`�l Phone <br /> Contr.utorui►1__-�q �3Q A1'• �OrC' .?pfiont!�"8'Z-g56-C� <br /> Lice <br /> TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT f i I DESTRUCTION i_I <br /> — -- -- PUMP INSTALLATION 1:1 SYSTEM REPAIR El I OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK �..- SEWER LINES DISPOSAL FLD. - _ PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL__ PITSI5UMPS <br /> INTENDED USETYPE 01 WELL PROBLEM AREA CONSTR_UCTiON Sri_ IFICATIONS <br /> F1 industrial l Open Hnllnm I7 Manteca Dia. at WellEsca.ation�� l --- Dia• of Wald lasing f <br /> I I Domestic/Private >�Gfavnl Pack Cl Tracy Type of Calling-?✓< M 5pocifications. <br /> I'I Public I r Othcr I i Delta Depth of Ginut$oal 'k Typo of Gro rt�MlQ I <br /> I \ k <br /> I I Lrntldt+wr - AvnmM. Depth I 1 Eastern Surlatn Seut Inatalktd t►y _...._. •-' <br /> Repair Work Done i I Tvpe of Romp Sltala nn <br /> Wdrk Do <br /> _ ,I .�,. - b <br /> Well Destruction I.1 Well Diammer Sealing Material Itop 5011 <br /> -L O-�_ Filler Material fBolow W) <br /> rrr�r•� Depth_St7-.__ �. ��._....__r........�. __ <br /> TYPE OF SLP11,, WORK: NLW INSTALLATION I I REPAIRIADDI•.JN I I DESTRUCTION I 1 INo;jsoptic systarrt *invited it puck sewer is <br /> Ii 1►vailaf�le within *invited <br /> E Installation will servo: Residence __._ Commercial— Other II <br /> Number of living units: Nuthher of bedroom% _ \' <br /> Character of soil to a depth of 3 franc . Water table depth W <br /> SEPTIC TANK 1'1 Type/Mig capacity— 1� � No.C~ments 1 <br /> PKG. TREATMENT PLT,1=1 3 !'p Malhod of Disposal <br /> Dislan-t to nearest: Well Foundation Prop MY Line <br /> s LEACHING LINE 11 No. A Length of fines Total langll 449 ---- <br /> }` FILTER BED I i Distance 10 nearest; Wolf Foundation_ fhttparty Lhts . <br /> SEEPAGE PITS �I I Depth SlM r . Nurrtbar, # -� <br /> SUMPS I I Distance to nearest: Well Foundation it . IProp�Lf". . <br /> DISPOSAL PONDS E 1 <br /> I hereby comfy that I have prel"It"d this epplicatiat end that the work will be done in accordance with San Joaquin County ordiAdinCI ,stag law&and <br /> rules and regulations of the San Joaquin Local Health Drlllrict. 11 <br /> Horns owner or licensed agent'%sklnalura cenifkts the following:"I certify that fM the perfotmanca of thlt work for which this permit fa laawd 1 tihall"of <br /> employ any person In such manner as to become subject to workman's compensation laws of Citfiforrra.'ij Controctoel;hiring or suD cantracting slgmlW a <br /> certifles the following:"I certify that in the performance the work for which this permit N Vssueb,1 Mall' Play G w�to �e I <br /> lion Laws of California." <br /> The applicant mmuuj1 -coil for +rood ins ctio Comptole drawing on ai r <br /> gg S nod x�`J'—"�^ = - f .r <br /> Title: Data: <br /> _0;09 DE ENT USE NLY <br /> �r—�— :ate/` "' ' <br /> Applicellon Accepted by IAre <br /> �il---�._ <br /> + Pit or Grout Inspection by Date Flea Inspection by Dau'�,1 � <br /> OX I <br /> AddIC"al Comments: <br /> f, Stk IN 6791 U Lodi Vg.3621 El Manteca 823.7104 D racy 936•G385 <br /> Applicant• Return all Copies to: Envoanmental Health Parmlt/Servkas 1601 E. arelion Ave„I P.O. Boit 1009, STI CA 85201 <br /> �FIT �AMOtir+t' �tle AMDiJNT —TTED a RECEIV6 B ,� CATE PfAMIT'fifl. <br /> F0 CASN <br />