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T;rF <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT !ay, <br /> 1601 E. HAZE:i ON AVE., STOCKTON, CA <br /> Telephone 1209' 466-6781 <br /> PERMIT EXPIRES_1_YEAR FROM DATE ISSUED <br /> --- (Complete in Triplicate) -- — "' <br /> 4" <br /> Application is r.elehy made to the San Joagr,m Local Health District for a permit to Construct and/or nstall the work twain described.This aFF-F 10"M <br /> n..tde in corny voce wah San Joaquin CouritJr*dmance at. 549 for sewage or No. 1862 for well%pump and the Rules and RoquWroro of the San Joaquin <br /> ocal Health rr ttrrrt x/038 / iT <br /> Job Address �`- ' —_. City J Lot Site � <br /> _� Pm <br /> Owner a Nam.• — -- - Address ..�G Pt"" <br /> _ Conhactn �!'" ref �_-"'_"—_C___1Wdress ��'— License No. _ Phab �_ <br /> 1 - - ! <br /> TYPE Of WELLIPUMP NEW WELL i i WELL REPLACEMENT 0 DESTRUCTION L) 1 <br /> PUMP INSTALLATION !i SYSTEM REPAIR CI OTHER f 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK __ —SEWER LINES _—_ DISPOSAL FLD. PROP. LINE __ •�+ <br /> FOUNDATION AGRICULTU_PE 16 ELL OTHER WELL_ PITSISUMPS <br /> INTENDED USE ._TYPE OF WELL Pf%OBLEM AREA CONSTRUCTION SPECIFICATIONS C <br /> Ll Indust..« -- ( ; open Bottom f i Manteca Dia. of Wall Eacav4tion Dia. of Way Casing <br /> C I OentasherPNvate I)Gravel Pack l I Tracy Type of Cas" Spscahcstions <br /> IPublic I 1 Oreton 1 I Delta ' Depth of Grout Seal _ Type of Grout <br /> I i b"LWoon Aplwo■ Dopth I I Eastern Surface Seel Installed by <br /> Reper Wc+k C,kine 1 Type of Ptimp _ N P. , ._,----- State Wort. Done-- <br /> NAM DaafrttttW Well Ownetar __ ____— Sealing Material Itop 501 _ <br /> Depth Filler Material l6olow 501 <br /> TYP( OF SI PI IC WORK. NEW INSTAI I ATKIN t I REPAIR1ADOIIION DESTRUCTION 1 I INo lira me system permitted d public sewer is (� <br /> available vwthin 200 lee!.) <br /> fnsta9ation --it spire Residence _ Commercial ____ <br /> YOther - ----_ <br /> Ntwnbar of kvmq units __–_ Number of bedrooms <br /> Chawcrer of -,A to a depth of 3 leer __ —_-_ —-- — Water table depth <br /> _ SEPTIC TANK Ak Type/Meq � --_-- _-- --- CapZ20 F No. Compartmnits <br /> PKO TREATMENT PlT I I Method <br /> ` Oiwann M ttrarast: Wale �------ Foundation!O -- Property lit lns.� <br /> A� <br /> LEACHING Ll%'f Ne. •L-01 0 a arias _ ra Z- - jotal Whip <br /> FKTER SED I 1 Diatanos 10 nseow: tf1AM Foundation _ Prapertp Lits <br /> SEEPA"E PITS I t Depth _, ,_.Sin <br /> SUM" 1 I Distance to Hast- WA Foun4alion —_-.__ Property Line <br /> DIS61( 'AL PONOS f <br /> 1 hwelty comity rets)1 have prepared thee apptiu.8110 Mid deal 00 wwk WON be done in occonttanee with Sart Joaquin OOIMMy c4dlrwinc'es, state tows. and <br /> nifts and nputaao.n of the San Joaquin Local►Mash District <br /> Houma Owner or licensed&gem's eignafun o" 11 the MrovmV ..I crmfy trial to the pe fortrome of the vtoN for which this permit is rated, 1 shag not <br /> antpiey&"poison r sixh,narmer as to oeeome soblect M wolNmian'k C 11ritatllatrWl Laws Of Caiforttia"Contractor's tWWV Of subCOnhaCtilltj Allnewe <br /> aartlfles the friaow" i(edify that in the performance of the vocit=too which the permit is issued,1 shah entp)uy Persons autilecl to WOO MW*s COmpanaa- <br /> *W latah o1 C.oliforn.a" <br /> The applicar.r mutt�I aP fpr�ayregi insoeehonw <br /> s Complete drawing on..n/se skip <br /> �` <br /> Slpr od x � /lI'�`V 1e}' ___ .__- halef-- <br /> I OR DEPARTMENT USE ONLY / dry �► <br /> Appkcalion A. opted i t Date �I l7 / A... <br /> Pit or Grout in-tact:on by sate_ _.-_ Final Intpeaion by Wte,l(j� <br /> Addrtiond Cool~*% _ <br /> 611 41166p,1111 I rwf. 310 3621 [! Manteca 873 7tH Tracy e3S 6306 <br /> Appkcani rta•wn an caput to ErwirorimterilM Health PermrtaSer­rst 11101 1 Hatelirtn Aw., P O. Boil 7000, Stk., CA 96201 <br /> /1t T AIANJ41 OUR AMOUNT 111MIT110 —Ca nteelvlo 9Y OAT[ P1RMn NO \ <br /> CASH <br /> rr I 1_ . +� Z` ��— 111 <br /> r►it • - --* ---- <br />