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APPLICATION FOR -FRMIT <br /> SAN JOAQUIN LOCAL HEAIIH DISTRICT <br /> 1Wl E. HAZELTON AVE., STOCKTON, CA <br /> Telephony (209) 466-Ml I _ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ..- <br /> (Complete in Triplicataj <br /> Application is hereby n, o to the San Joaquin Local Health District for a permir to corstruc:andAx install the work herein dasctibc_ TI" 'anon is <br /> nada in carnpEwice wsth Sen Joa iuln County OMinence No.519 for sewage or Nu.1082 for wail;purnp and the Rules and Reguk"m epuir, <br /> Local Hall Datoct. <br /> Job Address, - __ Cif; Lor Sae <br /> Owners Name (1/ _'tt"t, Add Phone �a ,yJ/f <br /> 3 Contractor',Name _ nae No. Phone y�/o T" <br /> T_Y,E OF WELL/PUMP: NEW WELL ❑ WELL REPIA.CEMENT G DESTRUCTION ❑ <br /> PUMP INSTALLATION C aYSTEM REPAIR C OTHER 11 �y <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DIS'06AL FLO. PROP. LINE <br /> FOUNDMTICN . AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WEL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial OtN+`5._ ❑Manuca Dia.of Well Excavation D's. Ol Well Casing <br /> � ❑ Domoetdc/PrMts G Grant Pack ❑Tary Type M C"ng--. Spa<ifiutiora <br /> ❑ public ❑Ofher ❑ Dello Depth of Grout Seel Type of Grout <br /> ❑ Ielgrtion --Approx. Depth ❑Easton, SQrmca Seel Installed by <br /> Repair Work Dora ❑ Type of Pump __ H.P._ Sum Work Dov <br /> Wall Desb%l ❑ Well Diamawt _ Sealing Materiel(fop 50'1 <br /> Depth Filler Materiel(Below 6yi 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION- R /ADDITION ❑ DESTRUCTION LItNo Wtic system n <br /> pen¢t J7 !publx sewer is <br /> a"Mble within 200 feet.` <br /> Installation will ww; Residence_ Cotnrye c 1 -7_ Other -JI <br /> Number of Wire units._ Number of roty)a (t��\ 1 <br /> Cherwtx M soil to a depth of 3 fest:FY - � Water table depth <br /> �� <br /> STN:TANK G Type/Mfg Capacity !1� No. Crnpartmanu 1 - <br /> PKC. I REATME14T PLT.❑ //� L Method of D <br /> Ulu:are <br /> ncs to treat: Wee T!•�Foundatiun ` Pr.rperty Lirw -— <br /> LEACHING LINE G No. 6 Lsrtgm lines __.���� LAITool Nrgthhite_ <br /> FILTER BED Cl Di.unu to rserest: Wall_�-M1" 6daaon Property Lira <br /> SEEPAGE PITS-_- ❑ Depth ¢e___- Number <br /> ❑ Dlsvatca to nserran. Thal: Foundation___ Property Line <br /> 9F AL PONDSL' <br /> 1 hereby onr0i, _here prepared this application ar..1 that tte work will be done in accordance with San JoaQuin county OrdimMea,sate laws, and <br />�1 rules and reguletiors of:fs San Joaquin Local Health Ciutrict. <br /> Harm awm,or planted agtrtt'r,sigmavre certifies ins foeoning:"I carJfy that in the performance of the work far whx;h this permit is iesue],1 shall not <br /> wft*y any parson in such rt.s+lar u to become subject tc w.orkrron's compensation laws of California.-Cont hieing or wb�ntrecting signal 7f <br /> cis tlFicr dxl oAowid.2:"I cid/r/that In the perfornsnce of the nw".Inr,Mrich this permit is issued,I shell employ persons subject to workmn'n corNmr-m- <br /> bat Wn M Calhwri4..I./or, <br /> The applicant m�1t{,at M cal S. ComrH,d. wing on r ze tido. 44 <br /> G� <br /> Signed%—//I_a'7"—/f)d__ C1�—'Tit Dam: C— <br /> FO PAIITMENT USE ONLY <br /> L-S <br /> Apphosvon Aacecn by/7. !fc/"''�' D-•a 1.,..r 46 Arid <br /> Ph or Grout InspacUGtb Firol Intpeak,n by ��/w` - Data P <br /> Additional Comments: <br /> ❑Stk 4656/81 ❑ Lod 389-7821 ❑Manteca 823-7106 G Tracy 835-8386 <br /> Applicant- Return a cupiss to: Etwleorrriantal Health Psmih/Serwk»s 1001 E. Ha:alron Awa., P.O. Boa 2". Stk., CA 96MI Q <br /> IN <br /> FIE M <br /> FO AWMOUNT NT WE AREMITTED Re RECEIVED BY DATE PERMII NO. 2 <br /> CASN Y <br /> . car oar low tam <br /> E _ <br />