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f 14�'• <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA <br /> ! i <br /> Telephom 1209)488-878] <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ° <br /> (Complete in Triplicate) <br /> >; s <br /> Application is hereby made to the Sen Josquin Local Heath District for a poi 0 to construct and/or YtetaE the work herein desetbstL Tlds appecown,is <br /> mads in compliance with San Jo:+quin County Ordinance No.518 for towage or No. 1802 for wolf/pump and the Rules and A g-1Onof titer Bas Joe i <br /> Local HAtth District. <br /> t <br /> Job Address _!7 � Cky Lot Sin PM i <br /> Owrsr'a Name U �Q_?_� Addraas –, .� Phoria <br /> Contractor _ �( maty cense No. <br /> TYPE OF`VCLLI I VviP. NEW WELL U 'WE-Le.AEFLACEME'iT U DES RUCTM O <br /> _ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O <br /> fr <br /> DISTANCE TO NEAREST: SEPTIC TANK SOWER LINES DISPOSAL FLD, PROP.UNE <br /> – — - A IRICULTURE WELL •_ OTHER WELL PITS/SUMPS <br /> �1?Ir•, <br /> INTFNC+'I 1 V,'a L PROBLEM AREA CONSTRUCTION SPErIFICATIONS r <br /> L Intwfltnal :L�i*rn f3ottnm Manteca Dia. of W,ti Excavation_ Dia.of Well Casing <br /> + O Oen n+stit-t' r utyel Pt -k : Tracy Tytw of Cast <br /> ng - –-----—– SOaciecatkxr <br /> E-.' Public 1 Other 1 ' Delta Depth of Grout Seal Typo d Grout <br /> lmigaticn __Jlpprox. Depth 13 Eastern Surfed Seal Insia ad by <br /> Repair Work Done C-i Type of Pump H.P. Rtate Work Dona <br /> Weft Destruction (; Well Diameter Seeing Material(top 67) <br /> Depth_ Filler Malarial <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/AOOITION Wr DESTRUCTION 0INo <br /> a➢O TMt.I a oubee casae►la <br /> waiwRlWl <br /> Installation Will serve: Residence'P Commercial_ Other <br /> Number of living units: -- Number of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK U Type/Mfg Capacity No,ComperbnwKt <br /> PKG.TREATMENT PLT. F1 Matted of D1 I; <br /> Distance to nearmt: Well Foundation Property Lire _ a <br /> LEACHING LINE JX No. 6 Length of line __. Total WV0/a <br /> FILTER BED U Dis!ance to nearest: We Foundation <br /> Property iter_ <br /> SEEPAGE PITS Cl Depth Ira_ s Nuni1w <br /> UM U Ontance to nearest: `Nell Foundation Property Lire <br /> ISPOSAL PONDS C s t <br /> I haraby certhy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordnences,atefls Islas,card i;ss1 <br /> rids and mgutstio m of the San Joaquin Local Health District. <br /> Home owner or Ik-6n ed agent's signature certifies the following:"I certify Mat in ter <br /> peAomtertoa of the wok for rNtlelt this panNt Is ktuMd.I attalt not <br /> employ any person in such m nner as to become subject to workman's compensetlon laws of CaMomia."Conftsctoes hk"or wub-oontreolitp algnatUra <br /> oartffles the follow ng "I carnfy that in the performance of the work'or which this ponn't in issued,I sheill MnPloy perm^,.atbjaet to wotltnlan's oompensa• t+ <br /> tkxt Isvvs of Caliiornla" <br /> The applicamv�+t a, r^q'"r.Z1. ntnectk". Complett('swing%l rayprss aide. <br /> Q Signed 'k-.qz– Ti". <br /> y FOR OErART1NFill T USE ONLY <br /> , <br /> ANkation Accepted by _. 7 l��1.I Dat_ ASM <br /> 11'"AtofF Inspection by Final ittapactlon by _ Does 4Y : <br /> Additional Comments <br /> ❑Stk 100-Ml 11 Lodi 309 MI 0 Mantas M7104 O Trwv 83544 <br /> AppMdnt-Return all copiei to: Environmental Hwftn Perm'/Servkw 1001 E.Ha hon Ave.,P.O. Boot 20Oe,11111k.,CA OW <br /> + INFO AMOUNT DUE AMOUNT REMRTFO CASH RECVVED By DAT! PrAw"O, <br /> .aH ta•24(Rev.r•set <br /> am 448 <br /> • o ., ��/Qto �0-110.0 <br /> ..' ,,.,h' :1�;'�M+.:+a,iLt4ho.., ..v.�,-.�:..�W:huiii,c.�:arJ:i"�er,",tf „ �itlR4•`Y�rI:T'ir:.na-:a.,, ,..«, •..,.v....n..w.wsnr .n.'wC;,�,:(>�^ f�:tS.:w+'k,r�Cr:, ,X;;Ir�j�• <br /> iJkhe«v ay. wr4a. k . <br /> e� <br />