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r3AN JOAQUIN LOCAL HEALT-i 0 Ir, <br /> '601 E. HAZEL <br /> 'TON AVE.. STOCKTON,? <br /> To;nphonr! 1209) 4666781 <br /> PERMIT EXPIRES I YEAR FROM[ DATE ISSUED <br /> (Complete in Triplicate) <br /> Appt,cin,on is 1,&ehy mad,In.:he Sen�e,Aqu,n 1.'Cap Hata,17!-It!-1 fo;a pe.-mit to a Zl'm­sla4 1hol wcrk herein descf1hed.This application is <br /> made in compliance with San Joaquin 7-cur,-v Orda.encr,.Na.543 for se-wage or No. IF4;2 for~la Porno and;he R uYs;!rd RopuJarior-,of the San.Jcecpsin <br /> Lc-al Health District. <br /> ict:Address :'r)'Size <br /> Owner's N;,mc AL <br /> PhCnn 7,%3------ <br /> contractor's Name Lj-�at,-, P11R,,ie.4�, 6-J Phone S,--y <br /> TYPE OF VVFLL,,PUMP: WW WELL VJFLL PEPtACEMEw DESTRUCTION <br /> PUMP INSTAI LATION ✓ SYSTEM RE-AiR OTHER <br /> DISTANCE To NEAREST; SEPI-IC TANK awEn L114ES ­­...- - -:SPf)SAL FLO. PROP.UNE <br /> FOUNDATION At7PR!CU'-T URE WEL� 07HER WELL PITS:SUNIPS <br /> INTENDED USE TYPE OF WELL PROBLEPI.AF3FA CONSTRUCTIONSPECfI:ICATjO,4S <br /> -- -­­ ­- <br /> lndusii,ia Ocen 3ottorn kla�llvca Dia.of%,V.rl;E,,c..vat-onsing <br /> Do.of Well Ca <br /> ic,Private Graver Pack Tracy Typo,of Casing Sporitica:ionr <br /> Fublic <br /> O'hel [),�Iw OvpTh a!Grow Seel Type 0 Grout <br /> Irrigation --ADProx. Depth E.!Stem Surface Seal Installed by <br /> Repair Work Done Typ�of Punto t�2A jj�z�­--- st'l.'DestructionWell Diameter _6'p wo.-k Done <br /> WrIl Destruction <br /> Sealing klateria!Itup 50': <br /> Depth Filler N'latLeW(8qZow 50'1 <br /> TYPE OF SEPTIC WORK; NFW INSTALLATION REPAIR;ADDITION DESTRUC 10.14 040 SC0111,System Permitted if public sewer is <br /> available within 2W foet.0 <br /> Installation will serve: Residence-- Commercial— Other <br /> Number of living units:_ Number of bedroom& PAYMENT <br /> Character of soil to a depth of 3 feet: Water tabViT <br /> SEPTIC:TANK i7. Type;Mfg capacity- No. c <br /> om <br /> W." 8 <br /> TREATMENTPKG.TRFATENT PLT 1- Method o"M sA <br /> Distance to nearest: Well— Founrjalion Property LineSA:tt�UJ?4 Cf1)j:N -11 <br /> R1,1C HEA1 I El: <br /> LEACHING LINE 7L No.& Length of lines Total Iengi h! <br /> FILTER BED Distance to nearest: Weil Foundation Proberiy Line <br /> SEEPAGE PITS C Depth --Size <br /> SUMPS 71 , D;stance to nearest: Well foundation Pre perty Line <br /> DISPOSAL PONDS L, <br /> I hereby certify that r have prepared this application and'ha!the wort will be cone in accordance v-pth San Joaquin county ordinahces,state laws,and <br /> rules and regulations of The San Joaquin Local Health District. <br /> Home owner or licensed agent't,signature certifies the following:"i C&;'fify that in the porlo,mancg of The work for which this permit is issued,I shart not <br /> employ any person in such manner as to become subject to wc,kman's compensation laws of Cari.1cmia."Cortractor's hiring or sub-comracting sign6tura <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shag employ persons subject to workman's con"nsa- <br /> lion laws of California." <br /> The applicant must call for:.If required inspections. Complete drawing on reverse side. <br /> Sig"m lle-16/1..—5r�z Title:L ' Date: <br /> FO SPAR &r UIS_RNLY <br /> Application Accepted by oatsArea <br /> Pit or Grout Inspection by Final Inspection by <br /> Additional Comments: <br /> 0 Sik 466678I r7l Lo&k 369-3E21 7, Monrnrui 823-7104 t7-Tracy M-6`MS <br /> Applicant-Return all copies to: Environmental Health Parmil/Services 1601 E.Hazelton Ave.. P.O. Flox I'W9.SM..CA 95201 <br /> FEE AMOUNT REMITTED C OArt <br /> INFO OUNT DUE PERMIT 140. <br /> EM 13-24(REV,IQM <br /> 1 29 m ry /45, ir, <br />