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Na/ t e <br /> -< <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON. CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> T.T <br /> (Complete in Triplicate) <br /> Application is hal made to Ma San Joaquin Local Health District for a permit to construct and/or install the work herein described.This spoication is <br /> made M complance w7N San Joaquin County Ordinance No.BW for aawage or No. 1062 for wall/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �y <br /> Jab Addition /-Z 9'F 7 c'.E'Ax✓T iC/N,f RIO City iPII X Lot Size PM -_ } <br /> OwneYa Neme ldSyy .�!/f/.✓r!A/ /N,�Addrea fi9iY6 PMne a ', <br /> Contractor's Name.nAO/A/fes f OOvVS L:coma No. 2101-- 71/7 Phone <br /> TYP£OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> - PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER C i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD.__ PROP. LINE ` u <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS 'f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> G Industrial ❑ Opan Bottom C Manteca Dia.of Well Excavation Dia.of Well Casing l` <br /> ❑ Don r /Private ❑ GravelPack ❑Tracy Type of Casing Specifications _ V rY <br /> ❑ Public ❑ Other - C Delta Depth of Grout Seel Type of Grout 7... <br /> ,C Inflation __-Appmx. Depth ❑ Eastern Surface Seal Evaluated by <br /> RapWork Done ❑ Type of Pump. H.P. Sate Work Done -* <br /> "- ' <br /> well Deatruebw Cl Well Disnetar Sesfing Material(top Sil " <br /> - Dopy FJW Material IBebw 50'1- " <br /> TYPE OFSEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION❑ DESTRUCTION G INo septic syr(em permitted if Pu <br /> - ! available wit'rin TDD feet.) ^ <br /> Installation MI"no: flaaidare�C 1_ Other <br /> Number f fivirlp uniu: Number of fsidroortla / <br /> Cturarty of soil To l depth of 3 feet <br /> _Waur table dap ' <br /> SEPTIC TANK - ❑ Type/Mfg Capacity-. ZI No.Compertmenta y� y <br /> Pill TREATMENT PLT.C j Memad of Disposal L1�� <br /> ' - - Distance to toaster: WNI /t:0 Foundation /O Property Una /J O/ .. <br /> _ LEACHING UNE - -- �- No.6 Length of race — O Total length/aiz / --" <br /> / u <br /> FILTER Bm .❑ 7irara:a m nomas: Well�1.rL- Foundation,..f' nS Property Una <br /> VSEEPAGE PITS ❑ Depth Sue <br /> SUMPS ". - - G Ditance to raaresc Wei Foundation ""- 'Property)late L DISPOSAL PONDS O ti <br /> I herebyaus cwtdy that I hprepared N16 application and that IIe work will be done in accordance wnh San Joaquin county ordinances, slate kws, and � <br /> auks and regulations of the San Joaquin Local Health District. <br /> y�! <br /> -Htene owner ole licensed spoor's spnmura carol tha fofl w nl"I certifycace <br /> that in the rcirna of Ne wont for which this permit n issued. I stall nct <br /> employ am/porion in such rrannar as to beci Viol workman's mmpeneation bwe of Caiifamia.'•Contnctola hiring or nito o-contracting trading signature y3 <br /> _.coraffi the foacAklg:"I xrdty that in da parformanca of the work for which Nb perms u issued,I stall employ Parsons subject workman's mmparlsa- yB� <br /> don awe of GBfa-nia." <br /> The apperattwar�t"in for/alit red nopecdans-Compete drawing on on rave li�- <br /> '-%grad X_(\/L/..-O C'-D�__..�1— i ids Osfa: . yg F <br /> DEPAATM2007ySIF 91 017 <br /> i <br /> Date <br /> Appgcaa:t Accepted by fl <br /> Iys . eta _ FI Inspection by 't (� Dau/ <br /> pit or Grwt inspection <br /> Additional Comnann:G • :3 <br /> _- ❑ Ss 4811437111 Cl Lad 1 C Manuel 6?3.7104/ Traci MS 'a : <br /> AppGeam• Return W ODPba m: &Nktpmlmtm Haeltrt Permit/Semco 1801 E. Hazenon Aw., P.O. a"20011. Sm.. CA%Zeal - <br /> f <br /> IX c RECEIVFJ]BY DATE PERMIT'NO. <br /> INFOAaaIXrrlT( AMOUNT REMITTED t;A6H <br /> .d Islas IRV..ad <br /> IN led <br />