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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> G Telephone (209) 488-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ^ ` <br /> (Complete in Triplicate) <br /> z Lwict Im apernit to construct and/or install the work ocal Application is herebY�t JoegS n Coougui Ordinance No.nit torfor sewage Or No.185'1 to well/pump and the Rules and This awication is <br /> 'ReguaI i t d0SCIions of the San Joaquin <br /> made in cornpkance ' n. <br /> 1 Local Health District." S c "M Z <br /> pm <br /> Job Address 9�1 , . to 3 <br /> w.az <br /> Address W <br /> _ Owners Name__---- / .h <br /> Contractor;� 41& ddtess or_l �s:Z— —License No.Q+�.��-Phone <br /> TYPE Of WELLfPUMP: NEW WELL O WELL REPLACEMENT 0 pESTRUCTION O t <br /> PUMP INSTALLATION O SYSTEM REPAIR IfJ OTHER tJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _.. DISPOSAL FLD. PROP. LINE C <br /> FOUNDATION _AGRICULTURE WELL .OTHER WELL PITS/SUMPS <br /> `r <br /> INTENDED USE _TYPE Of WELL PROBLEM AREA CONSTRUCTION SOECIFICATIONS I <br /> O Industrial O Open Bottom O Manmca Dia. of Well Excavatione�- IL <br /> t p7s, of wan Casing i <br /> SpaciBcations 'D Do"aticiprivate C Gravel Pack ❑Tracy Type of Caefrp�I1 P � 4 1 Dtltar 6 Doha Depth of Grout Seal iy Type d Grout ID irrigation _ Approx. Depth O Eastern Surface Seel Installed bI ,Repair Work Done C Type of Pumpe £ {y.Well Destruction ?� We8 O'rarttetar Seeing Material(top SO'1Depth __,� Finer Material (Below 50')TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIAIADDITION �STRUCTIO �pens tad A t1r�l'clsewer Is/ / 2110 teatInstaiation wit serve: ResidenceL! CommertAal_ Other `- `'J`�Number of wing�ts: � Number of bedroo^'•��Chmacter`1af Soil to a depth of 3-feet: er ta610 depth tSEPTIC TANK D Type/Mfg A• C.$aciN ZeCompartmentsPKC.7RI:ATMEPIT PLT.C /' dio)Of Disposal� r•.M IDistance to neatest: Well -'v FIAA EWn kte tom- .,c _IL U� I <br /> Total Ieogthlsite <br /> 1 LEACHINGLINE = No-6 Length of Iktas � — I <br /> FILTER BED C Distance to nearest: Wall,._L__ Foundadoliltz — ,T�oP«M Lines...-- t <br /> SEEPAGE PITS C Depth —_Size- -- Numbed <br /> ' SUMPS 4 U Dwaoce to nearest: wait d t�—.— - ,PropeM Line <br /> t I <br /> s DISPOSAL PONDS ;1 ) t <br /> I hateby Certify that I have prepared this appl:canon and that the work will be dote in accordance Wh San Joaquin county ordinances,state laws, and <br /> ' rubs and roqulatiom of the San Joaquin Local Health District. <br /> Home owner or hconsed agent's signature certities the-followings l•cenkythat M'theyerfonrwet ilomYhe-wo nac% es Nt"�g' psub- o issued, I igen not <br /> employ any person in such manner as to become subject to workman's componsato am s of so.I U'Colorado o hirirtbjec sub-c rinna tlrtg mpatura <br /> cenifgs the following:"I certify that In the Performance of the work for which this permit b issued.i shall employ persons wlipct to workrtrari s camPnnaa <br /> tion laws of CNifornia." I 1 <br /> Tne app5aanl must can for an vii_Td u+specwns. COmpinle drawing an rayatse side. <br /> Signed X_ Teale: r Dote: <br /> --- , , <br /> 'FOR DEPARTMENT USE ONLY I <br /> Dau 19t� <br /> . _ Area <br /> Application Accepted by ?. <br /> r <br /> IlKKt by_. Final ktspecV ,�,�y"Cg Dee <br /> I Pit or GIoutynspecdon by d <br /> 0 Stir Comments: <br /> Conen[s: <br /> ❑Stir 406:G7g1 a Lots 3W3621 0 Menten =-7104 O Tracy 83&63A6 <br /> Applicant^Rerun 86 capm <br /> es to: E"Are.neKal Heekth.Vam7k/5ervicea'1 1 c-liatshm!.Av�:�p.O.yBox 2009.Stk..CA 66101 <br /> tFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM1UT'NO. , <br /> tt <br /> INFO <br /> xt <br /> ♦M772e a1EV.l/ee> 5-53 <br />