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4 <br /> APPLICATION FOR PERMIT r <br /> t.- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E. HAZELTON AVE., STOCKTON. CA' <br /> Y � <br /> Telephone 12091488-8781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE MUED. r I <br /> (Complete In Tripi ca") <br /> Application Is hereby made to the San Joaquin vocal Health Distill for a prrrri t to ca otnret and/a Metall the twerp ho Mn dssaI Thb applool n Is "f <br /> €''-mada In compliance with Sen Joaquin County Ordinm No.619 tw sewage or fro.I=for wMJpump ant!On MAW W d R qualm uta 01 Ora SwrJatq m <br /> Local Health Dittdct, <br /> Job Address .y. _. or L J City Lot Slaa pM <br /> Otwrter'a Nana Address /hiKZ Qd Poona _ <br /> �-,ConIractotif��} /ft EXPLc�/2f7' ,rdOre ss <br /> _Lketisa NeI�(1�� Ph m. <br /> 4 <br /> •hk4YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT, .© DESTRUCTION p <br /> ,t ti�Tp <br /> PUMP INSTALLATION CI SYSTEM REPAIR'0 '" °''01HEII jEm Wt?RMII* Akc t i <br /> , '*DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , PROP. <br /> UNE l <br /> FOUNDATION AGRICULTURE WELL`�`"�_ '" QTf1ER'1NEiL' '';'PITS/BLIMPS ' <br /> } NOED USE TYPE OF WELL PROBLEM AREArCONSTRUCTION SPECIRCATWNS <br /> �'„ca,gip, In�rtsdfal�MDrurypatraltG7 Olmm Bottom ❑Msntsoa ' h50Ia.of Witt IcrograUt]n " ~ <br /> ? p<DomssthslPtiva ❑Gravel Pack C3Tracy Type of Spaolllpaypna <br /> ❑Public 0 Other ❑Deha ' Oepnt of Grout SsaIA � Typo d amtrt ff aimmm <br /> ❑Iripytlon —.Approx. Depth ❑EnWn v"' SwimBMI YislMad ivs <br /> Repair Work Done ❑ Type of Pum <br /> p H.P. Stara Wtlelt bot+a <br /> c' WsA Destruction ❑ Well Diameter Sentara Marsfirl(tap 60'1 <br /> r <br /> Depth FNsr Wt m Iesklw S9'I <br /> r... TYf E OF SEPTIC W NEW INSTALLATION❑ REPAIRIAODIT1011❑ _ 1 sept� <br /> * e p l t sawn b ! <br /> ppm M <br /> -avalshls ]OD hN�}� <br /> lrtstailation wIl serve: R nce_.,_,_ Commercial_ Other <br /> Number of Ihdnp units: tuber o1 bedrooms _ <br /> Chersctsr of soil to a depth of 3 loot. ttleM � �; a <br /> F s SEPTIC TANK 0 Type:Mtg wilt" <br /> mit aipth <br /> PKG.TREATMENT PLT.❑ mstftod of OltPasel <br /> Distance to nearest: FautndrtitnLkm <br /> ,,,`_ t <br /> LEACHING LINE ❑ No. R Length of lines ~T *Vth/dzl <br /> ?' <br /> FILTER 8E0 L7 Distance to nearest; Well Plawty tiara <br /> SEEPAGE PITS ❑ Depth Site <br /> SUMPS ❑ Distance to nearest: Wee. Foundadsn �q. F <br /> DISPOSAL PONDS ❑ <br /> 1 hereby earthy that I have prepared this implication and that the work w11 be done N sccordaros WM San Joaquin oat"war ordMrettse,sate lam attdk <br /> k" rubs and regulations of the San Joaquin Local Health District, t I <br /> v„ Home owner or licensed spent's signature certifies the followIN:•.I oerWy that In the performartoe of alta work for which this pstmNt IS bPAd.I shse not <br /> employ any person in such manner as to become subject to workman's oortpsemation Ism of CaKornfa."Contractors Mtft or sub-oo Mectbtg etgnapwe a?r <br /> { c Co.lfles the folorvktg:"I certify that in the performance of the work for which this pemrt is hied.l dTA employ pehwn Srtblstt to workman a oom omme - f <br /> i, 11 tlor laws of Callfomia." . ' A .y . <br /> J The applicant rnust call for all requirad inspectiome.Complete drawhrg <br /> Signed _ _ <br /> This: ME -Dow <br /> ABnW USE ONLY. •� � <br /> Application Accepted by Dowr <br /> :6 <br /> Pit or Grout I W-nor AK <br /> pea fh1N hwpeceen <br /> 1L-a3t� <br /> Addltkwwl Commen —jog r <br /> ts: <br /> ❑Stk 411111-MI ❑ Lodi 369-Wlel ❑Ma p 823-7101 C]Tragi4=V <br /> Apokont-Return all copies to: Environmental Health Pamtlt/Swvkm 1001 E.Mevs tt Am.P.O.Bert 20III,Stk..CA 0=1FIFE s <br /> t <br /> INFO AMOUNT DUE AMtx1Ar'REMtTTEO GA8 RtCEtm BY DAT1 RERSAIT NO. I I <br /> a L t11EV. e e: V'S` o ty ' M 1 <br /> I0 rfr�ZO - 0"�S <br /> ?3- <br /> •'�p.� �r v�4 � s��J'J.�'.1�t�a+ls+�r .av >`.�' 4{�l7dF;�.1�{�f�J�'„�+3%� �s ti.�.y ,,,;kr £E ..� <br />