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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 4666761 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appl.cahon s iuv.•hy m.!v,m-hi. San Jnanum Local Health Disthct for a permit to construct andlor mstall the work herein desenmil. This MI cation a <br /> made m LnmPi.anu•.ini':nn (..Joan`Con„)y Ow..ance No 5.19 lot sewapa or No 111152 Out will-pump and the Rules and Regulations of I"San Jnagu e, <br /> Local Health Dnue.t <br /> Job Address 1�.• 7�Gl1_... L �' --�-+ - `- City JJ_?I! rl Lot SNa /l e- PM <br /> Owner's Name Q4 '}.3M IL,) _. _. . AdMess ._�-�I��J..U.. -J�FGl� )P ._ Phone <br /> Contractor �•iEi .lAddmrss 10.) -V 1 a]L/ JA0�)��f License No. 3PRor6 'f i'� <br /> a <br /> TYPE OF WELL PUMP- NEW WELL WELL REPLACEMENT DESTRUCTION i i <br /> PUMP INSTALLATION SYSTEM REPAIR i OTHER 61 <br /> DISTANCE in NEAREST EEPTIC TANK .- _ SEWER LINES - --__.- DISPOSAL FLD.__ PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -_ — PITS/SUMPS _ <br /> INTENDED USE ivPl OF WELL FIR OBOE M AREA CONSTRUC ION SPECIFICATIONS_ O <br /> Industrial OPen ar,vnm , Manteca Dia. of Well Fsc.1vation _---_- Dia of Well Casing <br /> Domestic.Private Gravel Park Torry Type of Casing ,_ SpectRcatlpa <br /> Pub(¢ Other Drita Depth M Grind seal _.. _-_-.___-- Type of Groul <br /> I Irigldunri Appyns Depth Eastern Surface Seal InstaRad by <br /> Repair Wort Donr Type of Pumn <br /> ml, __. ____ _ ____ __ State Work Oona ___ <br /> Well Destruction W.111 DeanMrr _. . Soal.ng Material IDR]501 <br /> Depth -___ __ Ether Material IRnlow 501 <br /> TYPLOFSLPTICWORK NtWINS7AILAtI0N (If I'AIR'AODITIUN /OLSIRIICITIN INo sr'phc syilem permitted it public all n <br /> ai,&IA r.,thin 200 feel.) F <br /> Inveliation wiH servo Rrsubnce Commerciale Other yRst A-J <br /> Numbnt of hying unds Number of Wools irs <br /> Character of sod to a depth l,1 3 fret <br /> SEPTIC TANK Type Klfo .-._. - _. . CApaLity _ No. Compartments <br /> PKG TREATMENT PIT Mr,Ihort of Disposal <br /> Diwldnrr to nearest: Well __ - Foundation ____ Property Lean <br /> LEACHING LINE No & Len0lh of lines _ _ - Tate[lengthlsim-._-- — <br /> FILTER RED Mstancc to nearest: Well EmnMatem .. Property Leta <br /> SEEPAGE PITS w Drpdi •J1 T_r - Sue ��s_ Number, <br /> SUMPS Ui Ance m nVamst Writ Orri Foumlaunn SQ'-_ Prop"Lira <br /> DISPOSAL PONDS <br /> 1 hereby cerply thdl 1 hdvr m•'pd•MI this dppliLdhon and that Iii,.ork will he darer er accordance will,San Joaquin county wddances,state i.ws, end <br /> rules and legeldhnns of this San Jii.upnn I ural Health DiVil I <br /> Floom nwnnr nr hu•nsrN ngnm,syp•nLun cnrhhus Ihn following i caddy that m the IKafnrmance of the work lot which this permit n issued, I shah evil <br /> employ any penicillin such manner:..in Ia.Cume subloct lu workman s cumponsalmn laws of California•'Contractors hiring or sub conuachi s,gralure <br /> camfms the folln.mg "I rr•rtdy that in pie Imdrnmanca of the work for which inls Permit is issued.I shall employ persons subject to workman's comperusa <br /> Lon taw,M Caldormd <br /> The epluhC lot mus)mall Inr MiltupirMl""mLhons Coml,low dlawmp on reverse su10. <br /> 7tln <br /> FUR DEPARTMENT USE ONLY <br /> Apphreunn An npmq 4, I- +y - •-� C.� Dates --.e�� � Aew _.[_ _.__ <br /> ). 1 <br /> Pit nr Grout msP•inn+n nv f. .. . i D.mi L!'�s�• _moi Final Impaction bP.i �.�.` -7' Div- <br /> Pit <br /> m <br /> Adddmnel Comnwnta <br /> . Stk 4665781 Lwb 3693x:1 Manure R23 7104 1 ' Tacy 9356M <br /> Applicant Return All rmm.,;i, F".•i-"'loaned Health PerrniiServrees 1601 E Hat•hnn Awa, P O on.M. Sri., CA 95101 <br /> AMOUNT RI MiTt[D K s 1 At Cf N[D <br /> It DATE PIRM17 NO ' <br />