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A <br />r 'Owner's Name .1 &A /712d Address Phone 3T 102 <br />The applicant all regt 'red plate drawing onrevars4iidC, <br />Signed X Title: <br />3 APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES l'YEAR FROM DATE ISSUED _ <br />(Complete in Triplicate) <br />Application is riteehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 18E2 for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health District, <br />;5-q ) " 19 —A7 Job Address City Lot Sue PM <br />4 <br />1 <br />'Contractor N• Si. 4'4 '4.:;-;it'r AddreSS3f70 ki f6-4"/ 114/License No, Phone <br />TYPE OF WELL/PUMP: " NEW WELL 01- •-• l• WELL REPLACEMENT 0 ' DESTRUCTION Li <br /> <br />'PUMP INSTALLATION E "SYSTEM REPAIR ;i1 OTHER <br />) <br />, <br />DISTANCE TO NEAREST: SEPTIC' TANK ' 'SEWER LINES' ., .._ ..,.. DISPOSAL FL D.L ____, PROP. LINE <br />PITS/SUMPS FOUNDATION ..._____ AGRICULTURE WELL _ . OTHER WPLL <br />INTENDED USE <br />0 Industriai <br />Dorriestic/Private <br />Public <br />I litigation y <br />Repair Work Done <br />Wet Destruction <br />TYPE OF WELL PROBLEM AREA., CONSTRUCTION SPECIFICATIONS <br />[Mfl Bottom U Manteca Dia. of Well Excavation <br />L. Gravel Pack <br /> <br />Tracy Type of Casing <br />Ii Other 0 Delta Depth of Grout Seal <br />77AfiliTeit7Depth —in Eastein - Surface Sea <br />Type of Pump _2' H f N,,State Work Done <br />Well Diameter Sealing Material ltop 501 <br />Depth r der Below7,501 <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIR ESTPUCTION . iNo septic system permitted if ou <br />available within 200 feet.) <br />Character or' soil to a depth 01 3 teat: :574-111C4,_ <br />Installation will serve: fleicterice Commercial__ ')-Other <br />Number of Wing units: Number of bedroorry 0; .134.77f <br />Water table depth <br />SEPTIC TANK- H Type/Mfg Capacity <br /> No. Compartments <br />PKG. TREATMENT PLT, Li Method of Disposal <br /> Foundation Property Line Distance to nearest: Well <br />tic sewer is <br />("C) /4-- <br />LEACHING LINE <br />FILTER BED " <br />k."---rfsici.8 Length of lines <br />11 Distance to nearest: W <br />Total length/size <br />ell Foundation _ „ Property Line <br />SEEPAGE PITS te-liepth Size ',Number , <br />SUMPS <br />Distance to nearest: .Foundation • Property Line <br />DISPOSAL PONDS 11 1 <br />I hereby certify that I have prepared this 'application and that the v,vgrk -Wili be done in accordance with Sart Joaquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin' Local Health Di-strict, <br />Home owner or licensed agent's signature certifies the following: "I certify;that in the performance of the work for which this permit is issued, I shall not <br />employ any person in such manner as to become subject to workman's compensation taws of California.- Contractor's hiring or sub-contracting signature <br />certifies tho following: •'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- <br />bon iaws of Calif. nia." <br />Application Accepted by <br />Pt ))r Grout Inspection by <br />FOR DEPARTMENT USE ONLY <br />Date / ir7 <br />, <br />Di 13.24 IRtV. .1` <br />Sol 14,211 <br />Area <br />EE <br />IN FO AMOUNT DUE:1 AMOUNT REMITTED Cit. I <br />CASH RECEIVED BY DATE PERMIT 'NO. <br />a <br />--7 0— CAA.A.14.___, / 7/? 0 9040 4' <br />klq Ins pection by 1.--.4.ei_00-,4"' Datei•-iecr42.1( <br /> <br />Additional Comments: („L.-.. \k-N <br />C.73 <br />0 Stk 466-6781 ET Lodi 369-3621 0 Manteca 823 71 o4 - 0 Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Perm-A/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201