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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1001 E. HAZELTON AVE., STOCKTON. CA <br /> Telephorm :2091466-67811 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> -- '-Complete in Triplicatel -- <br /> ppkcahoe n hereby made m The Sen Joaouin Local$faalth 0110A t fa a Perrrot to consirun aratror"so tts war Inrskf dem bad.TNS Ndcwic"is <br /> sde N campkrrce wins San Jowfuse Clamor Ordnance No.569 fa aewaga or No. 19621W w+araumP and the Rulas and Raaltl "M Of the San iosq i <br /> Mal Hao"District./�� � A� <br /> ab AddrEes �11•_�_! r`�E - P D —_ City -c n La Srte� <br /> wrois NamE C flArL�r �,RCt 1 _ Add-ons _ �~ <br />:e11bacla1 )ALT HALL- AddresS LicemeNo. " —(,!R2fphm <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> IISTANCE TO NEAREST: SEPTI'-TANK SEWER LINES DISPOSAL FLD. PROP.LME <br /> FOUNDATION AGRICULTURE WELL OTHER WELL RTS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_SPECIFICATIONS <br /> 1 hdualdal ❑OpSn Bottom ❑ Msntew Dia. of Well Excavation _ DY.of WN Caalrq <br /> 1 Darsalic/Private CI Gravel Pack f I Trecy Type of Casing Specifications <br />'I Public I'. Other I I DNa Depth of Grout SNI TYPE of Grout <br /> I Inigalloo _Appnaa. Depth I I Eeslnro Surface Seel Installed by - <br /> IepSe Work Dona U Type of Ptenp H . _ Stare Work Done_ <br /> Vol Destruction ❑ Wall Duman- __ Seating Maralel ROD 50.1 <br /> Dwh M-FIMarodal(Below SIX) � <br />'YPE OF SEPTIC WORK: NEW INSTALLATION PAIWAODITION I i DESTRUCTION I I INo septic system Danrmrted if pnbac sewn is — <br /> avNaaM within 200 feet.l <br /> Iron nor wN aerva: Re idencs pmnNrClal_ her <br /> NulnlN o1 kvirW units:I Nulnbar of W 0010 <br /> r Jugmref of sod to a dNth of 3 feet: " Water table depth <br /> iEPT1C TANK "✓Type/Mfg GPxiN No. Compartments <br />'KG. TREATMENT PLT.0 'Q AI L 1^Z` r n Method of�p�sofosal <br /> Dialaftpe to nearest: WeE I �j U Foundation G Property Line 1 LLL <br />.EACHING LINE la-4W6 Length of OneE=_a Taal Nngth/a1N <br /> l <br />:ILTER BED LI Distance to nearest: WN ' �TFoundation Property Lina [ (1 <br /> iEEPAGE PITS L✓Oepth _)Sin ._. �-1C_._— Number <br /> iUMPS t I Domenico to neared: WN __ ___ Foundation Property Line ., <br /> 31SPOSAL PONDS F1 7 <br /> zi <br /> hereby certify tint I have prepared this application and that the work will Le done in accordance with San Joaquin county ordinances. state lews, and <br /> ulm and regulations of the San Joaqu l Local Health Dilpict. <br /> iome owner or licensed apent's signature certifies the following: -I pertly,that in the performance of the work for which this permit is issued. 1 shag out <br /> employ any pennon in amh nynnsr as to become sublect to workman's compensation leave of California."Contracto/s hiring of sub-contractir g signature <br />:erifias the following:"1 comfy that in tine performance of the work for which INS permit is issued.1 Nall employ persona subject to workman's compensE- <br /> ion 4ws�kfsalilwnia." <br /> rhe applicant mei a all fo, hriqu <br /> _—plate aw�np on(�q�Verse sib'/�� '.s <br /> Title: <br /> Data: - <br /> a —_ <br /> FOR DEPARTMENT USE ONLY �^ <br /> %pPgcation Accepted by _1LLJ -_ Date <br /> sit or Graf Inspection by Da-" Final Inspection by n Jy <br /> I <br /> kddihoNl Cummann: .A L - / alt •+ �r / <br /> 1 Stk 46647el ❑Lodi I iJ Mantsu 8737101 1 acy 836 <br /> kpplkmt • Return Eg copes to: Environmental Health Permit/Services 1601 E. Hatelton Ave.. P.O. Boa 2009. Ss., CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMn'NO. <br /> INFO <br /> Unity .., '�c> <br /> s <br />