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;_M ! MMI :1410­ <br /> r <br /> _ r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIfN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> f Tolepllone(209)4664M <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heFeby ms"to the San Joaquin Local Health District for■permit to construct and/w install the work her � ppl' <br /> made in compliance with San Joaquin County Ordinance No.SQ for sewage or No.11162 for well/pump and the Rules a ns�ilp Sa n . <br /> Local Health District. <br /> Joh Addrtu`s j&AfjA-^Rt-&,,s c— _57M 41,'-S _ C as spit I- City clUbg —Lot Site � co <br /> � yocK9a, <br /> Owner's Name. S'2CI��l,Wo_Add,., q,Y+—E1 b0,V S 7 Phone <br /> ��d,t7'eR 4Ys3� <br /> Contractor Address G License Nord k a�Pltate� <br /> TYPE OF'VVELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION Q <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IJk <br /> DISTANCE To NEAREST: SEPTIC TANK SEWER UNES DISPOSAL FLD. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 iod+strid ©Open Bottom O Mantaea Dia.of Well Excavation Dia.of Wed Calfuv <br /> ❑Doom**/Private 0 Gravel Pads ❑Twy Typo of Specifications <br /> ❑Publicfit Orh�a�rprr�p �3 Dana Depth of G=n Seal �� of- _—_ Type Gran ;' <br /> . � E <br /> ❑In" ' LC So%i °��O'.Depth ❑Eaestom Surfem Saai Installed by o <br /> tlxpsir W'aide�3one ❑ Type of Pump H.P. State Work Date <br /> Well!DMIructiat O Wed Diameter Sea"Materiel(top 50') <br /> Depth Fikr Material Maim WI <br /> TYPE OF SE WORK: .NEW INSTALLATION 13 REPAIR/ADDMON❑ DESTRUCTION❑ 1 tic system permitted if public sewer is <br /> avalleble within 200 feet.) <br /> u Installation cell) Residence_ Commercial_ Other <br /> Number of kvittg Number of bedroom)$ <br /> Character of sol to a of 3 foes: Water table dept:% <br /> SEPTIC TANK O /Mfg Capacity No.Corttpartcronn <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Dictanoe nearest: <br /> W.,1— <br /> ell Foundation Property Line <br /> LEACHING LINE :'. .._❑ No..&Lalgth of Total lengdr/site <br /> FILTER BED O Diatmice to eR Foundation Property Lin! <br /> SEEPAGE PITS IJ Sime N11 Number <br /> SUMPS ❑ to nearest: Wen sudation Property Line <br /> DISPOSAL PONDS ❑ <br /> I haaby certify that t hm Wapwsd Ulis application and that the work wiN be done in accordance with Sen Joaquin county ordntancas,state rams.and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or lioanmed sgamt's agnature cartifles the following:"I certify thst in the Performance of the work for which this permit Is issued.1 shah not <br /> wnploy any parotin in vich miriner as to become subject to workman's t orrvil leation kwt of California."Contractor's luring or Subcontracting Signature - <br /> coa fiea the folowitg:11 ow*that orrranoe of the vxwk fa which this psmrt is k rood,I shag employ persom subject to workman's r;omlpensa- <br /> tion)antra of <br /> Thea nt st tall f!- .0 regttMsd psetioctt.CornpleM drawing on retrains <br /> S' a rroe: Obi 1 16 4,4 dAF9-Date: <br /> - - - - - FOR DEPARTMENT uSE ONLY <br /> Application Accepted by Cale Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> 1 Additional Comments: <br /> O Stk 48&8781 0 Lodi 309-3821 ❑MAntoce 823.7`104 ❑Tracy 83&Mffi <br /> Applicant-Return ad copiaa to:Environmental Health Permit/Swvieas 1001 E.HazaRon Ave.,P.O.Bos 2009,Stk.,CA 96MI <br /> E AMOUNT DUE AMOUNT ReArrrm rK 11 CASH RECEIVED tin PATE PERMIT'No. <br /> ♦flu 71'-N tRtV.l/e3! INIZO - <br /> Fm 14-a 14-a - <br />