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r <br /> a ' <br /> FILE COPY <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISI RICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 4209) 46687S1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate? <br /> Application Is hereby made to the San Joaquin local Health District for a permit to construct end/or Irm all the work herein described.This application Is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage of No.IBM for well/pump and the Rupee and Regufeftm of the Sen Joaquin <br /> Local Health DIW;ct. <br /> i <br /> Job Add. 17 3 9 /l�,�1�t�� °C u,t,- Lot site wit <br /> OwrierY Name A Aridness <br /> 173-71 Phan <br /> =` <br /> �ff�� bT <br /> Contrac " . �_Address l:�% [?Y 7d� License No' n�° <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ='-.DISPOSAL FLO- PROP. LINE : <br /> ` FOUNDATION 7AGRICULTURF WELLA' OTHER'WELL ''`' I P17SISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS } <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia,of Wall Excavation Ola.Of Wen Casing <br /> ❑Domestic/Private ❑ Gravel Pack ❑Traof Type of r'esittg_. SpacNicattorn rf,. <br /> ❑Public ❑Other ❑ Delta Depth of Grout Seel Tyra of Orovt <br /> ❑ Wrigstlon —Approx. Depth ❑ Eastem Surface Sid IeuagMkd.by <br /> Repelr Work Done C1 Type of Pump H.P. State Work Dorn , <br /> Wali Destruction ❑ Well Diameter Sealing Materiel Itop 64'l <br /> Depth FEIer Material(Below t><I') +fit <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REP IR/ADDITION DESTRUCTION Q iN systemp�rrse1ttad if public sewer is <br /> DO <br /> ays�within 200 iset l <br /> liistaltetion win serve: Residence Commercial_. Other <br /> Number of living units: Number of <br /> f <br /> s Character of soil to a depth of 3 feet: Water table depth�12a: <br /> SEPTIC TANK ❑ Type/MNo.Comparmlefft ri: <br /> s �PKG.TREATMENT PLT.❑ Method of Disposal ". <br /> Distance to nearest: Well Foundation Properly Lim .v <br /> 1 A' <br /> LEACHING LINE W'No.B Length of litres / YD Notal wwvtht <br /> �• FILTER BED ❑ Distance to nearest: Wen Foundation .far Property Line. II <br /> L <br /> -,SEEPAGE PITS 0 Depth f 4 Size� � Number a <br /> • SUMPS"', !&'Distance to nearest: Welle�---- Foundation -1 Property Lhn X <br /> r DISPOSAL PONC" ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoequM caunty ordinances,stats hws.and " l <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed egert's signature certifies the fonowing:"I certify that In tura performance of the work for which this pemtit is' I shallnot <br /> employ any person In such manner as to become subject to workmen's compensation laws of Ce Romle."Contractors hkbV of mb-eontraethtp sigraUrre t <br /> osrdHes the folbwing:"I certity that In the performance of the work for which this pat is issued.I shall employ pepox a dgect to workmim's co woi t <br /> tion Ierw of California." ; <br /> The applicant cell for nl u Inspectlone.Complete drawing on reverse rf M <br /> Signed, ec.� Title: 11 Dae: y a <br /> FOR DEPARITIMEW USE ONLY <br /> .ADPIIratio <br /> n Accepted by Date — Ana ' <br /> Pit or Grout inspection by Dote Final Inapeetlmt by Oats <br /> I i <br /> Additional Comments: <br /> O Stk 4884781 ❑ Lodi 369-3821 ❑ Manteca 973-7144 ❑Tracy 83648M <br /> Appil ant•Return all copies to: Environmental Health PamAt/Services 1801 E.Hazelton Ave.,P.O.Box 2M.Stir.,CA 0=1 <br />