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<br /> APPLICI.TICN FOR PERMIT $°C
<br /> svo JOA,n,Gif: LOCAL HEALTH 01<_1k1CT
<br /> a F 1661 E. HAZELTO4 AVE., STOCK16N, CA PERtgT 110.
<br /> Telephone (209) 466-6781
<br /> ki .•r OATS ISSUED
<br /> SS PER1[T ExPIRE4 1 YEAR FROM DATE [SSI ED
<br /> (Complete" in Trlplirate)
<br /> l S i Xt1r .
<br /> Appltca!ion r. hereby made to the San k+aquin Local Healtn District for a permit to construct an�,/or install the work herein
<br /> described. This he 1Y,C It w n J f rQ;A4/Ee 549 or sewa9c ar Nc. 1862 for welllpurnp 1 � �}
<br /> and,the,Rut es t/�M �•[t l `'?a
<br /> rSubdivision name '
<br /> I': Job Address A .4
<br /> '�' ✓ —
<br /> y`
<br /> owner's,Rema SIS-,�^Address 7 +� "�r /� R�_Phone
<br /> t �r r}''"Contractor's Namt `��;;>T�•License No. Phone
<br /> F ¢� .
<br /> 'F✓{zrTYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [� DESTRLC710H❑
<br /> PLx4P IHSTAI,LATION �� SY;TtM RLPAIR ❑ 0."HER U
<br /> ya /jJ�• &] •,SEWER L INES _ &%J t a ��DiSPOS.L FLO. _ PROP, LINE f
<br /> h -01 STANCE f0 NEAREST: SEPTiC TANK t"_- +
<br /> AGRICULTURE WELL OTHER W:L, PITS/SUK S _
<br /> FOUNDATIONS
<br /> IMTEHDED USE SY7E OF WELL PROBLEM AREA CONSTRISCTSON SPEC[11CATiDNS 1 „• �:. .
<br /> ytJ:
<br /> Q,'ndustrialtf.en Bottom r]Manteca
<br /> Dia. of Well Excavation ?ti
<br /> "1" � omesticJPrivate ❑Gravet Pack []Tracy Dia. of Well GvsinS }
<br /> err f, luPvblte.•, ❑IOther ❑Delta Type of Casing
<br /> kar�y�(crJwV
<br /> Irrigation '
<br /> Approx. ❑Castern Specifica.ions �-_ oar 9tiI+)
<br /> Cathodic Protection Depth "
<br /> li i�C}tf ❑...,. ." Depth of Grout Seal
<br /> Geophysicel Type of Grout _051
<br /> �r•.' (]Other, Surface Seal installed by �n�g t
<br /> ?epair;Work Done❑ Type of iu,�p �C?�_H.P. State Work Done vy
<br /> !li'Des n 4e11, ilameter mow_ Sealing Material (top 50')
<br /> W tr tto ❑ "
<br /> Oeptn
<br /> Filler Material (Below 50')
<br /> , .,. r ,
<br /> ��. �TYFE OF-SEPT IC'WORK.. 'HEW 111STALLATION❑ " REPAIR/AL'D[T108 ❑ (No septic tank or seep.ge Piava11ab1eewithinv200cteet y is `yl
<br /> ?.r t r
<br /> installation w1l1'servl: Residence Commercial �_ Other' t°{; ;� `►
<br /> i.` '3rgc
<br /> Number of l/vfng units: Number of bedrooms Lot size '
<br /> * Water table.depth
<br /> }' aCharactero.f:soil'to"a depth of.3 feet:.
<br /> Capacity No. Compartments
<br /> SSEPTICrTANKt, ❑ •'Type/Mfg. ---
<br /> ! ,pKG,.,,R ATMENT PLT::❑ Type/Mf9
<br /> Capacity
<br /> Method of Disposal
<br /> 1.
<br /> JSEWAGE.SYSTEM ❑ Distance.to nearest: Well Foundation Property i� r5111 , ss ,
<br /> F NTs,DESTRUCTTOR s a, o I "
<br /> 7 tLE11CHIHG'LINE" (_J g .Total length/size, �thr
<br /> tb. b'Len th of 11nes' 1- ,'
<br /> '+ Well Foundation Property tine ]
<br /> IfILTEIt. ED' Distance to ncerest: W n tion a ,
<br /> +< ` Depth Size
<br /> . �SCEPAGE PITS, �].. P _
<br /> it Property Line '
<br /> SUMPSX.r (=J 0lstancE to nearest: Well Foundation 1 F
<br /> RTq < �CISPoSAL PONDS LI ! d
<br /> •.. .��ti..
<br /> fJ':1!hereby•certify that I.
<br /> have prepared this application and that the work will be done'in accordant! with,ian:Joaquincounty
<br /> ordinances.°state'1a�s;'and-rules and regulations of the San Joaquin Local Health District.'
<br /> ,` t Mpmebwner,or licensed aye�otCs signature certifier.
<br /> suchfmannernas to become; "I ceftifysu�ectthat ntohworkmank compensatiorice'of then lawsf of Callfornla.' i.
<br /> t` rJ parotic ts`issued, E shall
<br /> ."
<br /> ";.Contractor!s hiring or 11 not
<br /> tnemploy a signature certifies the following;","1 certify that in the performalce'Of-'the work •or which, Cy
<br /> v 11 i,. ,� his permit is issued," i shall employ persens subject to.workman's compensation laws of California., ?I
<br /> lhe'appl;tant must u11'for all required inspections. Complete drawing on reverse s1de.
<br /> 9 Title: (late: hr, r
<br /> fT .t:4, Sf ned X 7,}�d r,
<br /> ?+"q•s 4(' t A EPARTMEiiT USE ONLY Area Z, [ tk t66-6781 4
<br /> i e p Application Accepted by _ ��-Y �—�-- --� ©/
<br /> Lodi" iC9-9621 + t� 3t r
<br /> .A6ditional Cam,ents: ❑ Flanteca SY:1-7104 + Ty
<br /> Pit or Grout inspection by Date _ �
<br /> r' �._• Date06 ❑'-Tracr,'. y3f•6385 r , re�W� �(
<br /> JtJr Final Insp•;tion by. Y — - +
<br /> 4 n;.
<br /> y X .Apel}can '-;0.etur -all c pies Lo:'"Envlr nm! ealth Permit,/Service 601 E. ze1� Ave., P.O. Box 2009, 5tk., CA 95291' ti ip
<br /> f ` PERMIT H0. y +
<br /> AMOUNT REMITTED RECEIVED BY GATE ti� h`oi ri4i ? i
<br /> FEE BASE AMOUNT OUE.
<br /> T�ly'y INFO' �,
<br /> 10/8 500 t 1 2 y
<br /> ti + tri 1426 -REY. 10/82 f
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