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APPLICATION FOR PERMIT <br /> SAN JC ArU1N LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209; 466.6781 <br /> L PERMIT EXPIRES 1 YEAR FROM DATE ISSOED <br /> (Complete in T,-ip!Icatd) <br /> Appilicanon rs he.«ny rr ads to <br /> rn1 Sen uspurn Leal Health District for Latae H althcomDaru:e with Son Jwquin County Ordluence No.549 fur towage Or11No. 18b2 fur t to cwe I r{.0 np doll ILo fi 1 th'i Jyy ark nd 1 reguIauu rl of tthe Sant J turn <br /> Local Health Dlsurct�]' oaqu��, <br /> .. Jut, AddreL_4 _!,/ �/jo �"tC <br /> Clry _ (w Slru_.._ /r �.Lf�lr�•-_ PM-- <br /> Oridress � <br /> y 1 <br /> CUIIt/JC tali �-. -esS :`!e!/'�E� WI-x-1 iiiLn.t:nse No. <br /> I+ TYP_ CiF WELL;PU P: Fhone <br /> NEW W LL ;; WELL R. PLACEMENT ;i DESTRUCTIGN [7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR (1 <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER [7 <br /> ------ SEWER FS DISPOSAL FLD. PROP. LINE <br /> FUUNUO.TION _ AGRICULTURE WELL - OTHFR WFLL._-_— <br /> PITS/SUMPS1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA'i IONS <br /> Cl industnal <br /> 6-6;;n Bottom ❑Ma"ca <br /> a f Cl Domestic/Private DIa~eof Well xcavatwn <br /> — De. of Well Ca:.ingLGrarel pick LTracy Type _ <br /> of Caa.1y $pe.ri;:abune <br /> I'l P rbli i'1 Other n Della <br /> Depth ul Gruu Seat - Type of Ghoul_.-- _ <br /> I i IrnJIalwn _-Aptwox. DeFth I I Eastern ---- <br /> Surlace Seol IIstalled by- <br /> fJpa.r Work Done U Type of Pump _-_- H.P. _ - --• <br /> Walt nestrucbon f I Well[n,.rrwterS <br /> -- ----- ealing aerial(top 50'1 — State Work Done <br /> Deptn- _ -- Filleraturlal IBalov. W'r _-_—_- ----� --- <br /> YPE OF SLPIIC V10fW NEW INSTALLATION I I NEPA /ADDITIG N I I DLSIHUCTION I i (No sepflc syetum ` - <br /> permrttr J d pab Ic so"!Is <br /> Insralla.ion will serve: Resider e— avadobi within 200 feet.) <br /> Commercial Other <br /> Number of Lvrng units. Number of bedrooms -- • <br /> Charar"- of sod to•dE nth of 3 toot: <br /> SEPTIC 1 ANK U Tyle/Mfg _ _. .v -- ��yy W%ter table depth �'rl <br /> Capac.ty [/ <br /> PKG. TREATMENo. Comportments _ + <br /> F'7 PLT.O <br /> --- ---- Distance to IeYJ <br /> aleet: eUQ Foundation <br /> Method of Dy�sal <br /> i jf_ - <br /> - Prr,{arty Line � <br /> LEACFAI:­j LINE Cl No. 6 Length of lines -� <br /> FILTER Pco —2 -- �— Total length/Wile, <br /> L.� �-- <br /> ! I Distance to nearest: W� '7/) /1 pr <br /> ------------- Q Focndatwn -1:- oPerty '.ire <br /> SE=PA.;E PITS I I Depth _ Sl:e ---- -- -- _ --- <br /> --- ---. __-- Number-- <br /> SUMPS 1 1 distance to nearest: Well -- -- --.-- - <br /> Foundauun --. Property Line <br /> IN -__-- <br /> DISPOSAL POTS 11 --- -_- <br /> I hereby certify that I h ;e prepared this appliear'm and that the work will Le done in accordant„with 5Jn Juaqu,n county nrdrnancuu, state laws, anu <br /> rules aril regulations of the San Joaquin Local i.with District. <br /> F ° lcm:owner or licensed agent's signature I j <br /> ure Certifies the following: " Certify that in the periormanuu of the work for which th.s perm(is issued, I shall not • <br /> emp.oy any person:')such manner as to become wSiect to workman's compensation laws of California"Contractor's huln e- <br /> lion <br /> the follo-Nang:"I certify that in the periormilf"of the work for which this perrnrt Is Issued,1 shall um ju v or sub contracting tJgnawre <br /> tion laws of California." p y persons subject to wurkman's co-npen„I. <br /> Ttw applicant m st or mqu' i spsctions r <br /> drawing o rse side <br /> Signed X__ r� <br /> Title <br /> ---------- Date <br /> F <br /> DEPARTMENT USE ONLt <br /> t,4 Application Accepted byDatu <br /> ---__.. Area <br /> Pit'it Grout Inspection by to -- <br /> - Final Insp� .tion by 3^����i 1 <br /> bs� Datu <br /> AddiComments:oneComments: +��E �. �y <br /> iJ Stk 4h6 6781 ❑ I 369-3621 LJ Manteca 823 7104 r- - <br /> O Tr cy 8366385 <br /> Applicant - Rue n all copies to: Environmental Health. Fern-it/Services 1601 E. Hszalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> n A ` <br /> FEE AMOUNT UE AMOUNT RREf_AITTE3 K O <br /> INF r <br /> CA CEIVED By DATA PERMIT h0 <br /> E.r 11 it[REV 1 v <br />