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04/03/2002 1-4 19 G401:3G 4WER03NMEWAL "ALT--i rAGE 91 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E (fAZ=''.TORI AVE., STOCKTON, CA <br /> Telephone (2091466-"l <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete In Tnpitcate) <br /> Application is hereby made to the San Joaquin Local Heatth Disrhr t for a permit to construct and/or ittstalt the work heram dascribed TIm appiicatran to <br /> M01111 m wmpfrerum wrth San Joaquin Coumiy Ordinance No 549 for sewage ur No 1862 for wail/purrtp and the Rules and Regutadonr of the Son Joaquin <br /> Locsl Health D€ssrct <br /> Jut; Address f � .La!-` ._, C,tY_ - Lot Size PM <br /> Owner's3starne Addra Phone <br /> i <br /> Carrtraatur dress_ �0A9 lir f��,� License Noah. -3 Phonc <br /> TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT G DESTRUCTION ❑ <br /> PUMP WSTALLATION C SYSTEM REPAIR 0 MER L1 <br /> DISTANCE TO NF-AREST SEPTIC TANK SEINER LINES DISPOSAL F!»D__ PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRt1CTiON SPECIRC-ATIONS <br /> D Indusmal ❑ Open Borrom Q marwrera Lha of Weft excavation Dia of Well Caarng <br /> D Deme=CjPnvats+ ❑ Gnwai Pack 0 Tracy Typo of Casing Specif cMions <br /> ❑ PtabllC ❑ Other Z2 Deity Depth df Grout Seal Type of Grout � <br /> 0 Irngation __-Approx Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Darns 0 Type of Pump. H? _ - - State Work Dana <br /> Weft Destruction Q Wait Drometer - Saaling Mai9nai (top 50') <br /> Depth Filler Material t5alow 50'1 <br /> PE OF SEPTIC WORK NEW INSTALLA TION ❑ FIEpAIR/AD02TION,`sig' DESTRUCTION El (No septic systam aennitzed it pubAc sewer rs <br /> mmlis ole withal 200 feet) <br /> inst3it2tttm was serve Fto=denca— Commercial-)c Other <br /> A$mbar-of living inns_ _Number of Wdroorns_ <br /> Character of soil to a depth of 3 feet �OMS{-� _ ~- - - _ Water;able depth I- G <br /> SEPTIC TANK L-7 Ty0a)Mfg �` - - � - - C.apactty- J;OC' _ No Companmen-m � <br /> PKG TREATMENT PLT n Method Of DISPI3641 <br /> r <br /> Orstanae to nearest Wall Foundatiart Froverty Una <br /> r� <br /> LEACHING LINE ❑ No & Length of Imes Totai length/size <br /> FILTER 81r D ❑ Distance to nearest Wed[ Foundation Property lime <br /> SEEPAGE PITS J4 #3eptlt __��Size Dumber <br /> SUMPS ❑ Otnance to nttaresc well Founde+pan Property Line <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify that I have prepared this applieabprt and that tho wark well ba done in accardance with San Joaquin county ardinonous, stats laws and <br /> rules and regulations of trio San 1oaquin Local Heeltfr District <br /> }dome owntir or licansed agent s signature cerfifies the foikrwing 'I certify iftat in the performance of the work for watch this permit Is naued, I shall not <br /> ernoWy any person in auch manner as to become saublec•to workman's compensation laws of Cahfornla"Cantructor s Rinsing or whr-OnttactinA srgrtaterre <br /> certifies The following 't cartifv that in the pdrformanra of itis work for which thiz penins rs isxutid I stmill employ per=^W s..'bi6c•to workman's comparsa <br /> .fon taws of California <br /> The BQp;raattt resit all fat aft rggtuirtad lrtrt�eczrorts Cornplota atawing oR revRrs side <br /> signed X- D910 — <br /> F3R DEPARTMENT USE ONLY <br /> Asapiicativn Accapted by _ Date // Area <br /> Pit ar Grout In ispectlon by sista L F�c+e= tnjrpeawn by <br /> Aocirtronni Comments- G. <br /> 0 Stk �6?B7 0 Loll, k&= 0 Montacs 825-7104 C Tracy <br /> Applicant , Return ail capias; to Enuironrnanwl Health Permit/Servscas 7601 E Haassiran Ave, P D Box NQS, Stk., CA 25Mi <br /> IN=- ArAGUNr DIJEF AMOUNT REMITTED GASH R1 GEtVED illCK Ay DATE PE'RMR w <br /> c r <br />