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<br /> +� rty€ "r err � TM ,' sa APPLICATION FOR PERMIT 4 4 F
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> v. I 1601 E. HAZELTON AVE., STOCKTON- CA G
<br /> �i , Telephone (209) 466-6781 aF'
<br /> PERMIT EXPIRES 1 YEAR FROM DAT: ISSUED
<br /> V.
<br /> �:, .. ,
<br /> (Complete in Tripl;cate)
<br /> iApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or inr:all the work herein described.Thli applliatbn fa s fi
<br /> made In compliance with San Joaquin County Ordinance No.549 for sewage or No.1B62 for well/pump and the Rubs and Regulations of the San Joaquin
<br /> t Local Health District
<br /> )� . �X�IA,v-4''] E.-'1�v'�S•�/,RR�SY,}?,.�'vF�. Qp �,G
<br /> Job Admess - 3 D D �. G J Nr�/�i /`a City Lot SlzeM l
<br /> { Owner's Name fel/t (] Vy I F IV �d �, "N :.... r ���C
<br /> u -Address Phone }
<br /> L A 2{C C �,�ft F' ✓ N d 5
<br /> Contractor's Name' License No. Phone ;
<br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ r
<br /> 11 PUMP INSTALLATION C SYSTEM REPAIR OTHER U
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINE Q +
<br /> !J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .�r
<br /> INTENDED USE T,?E OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS f
<br /> i
<br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia,of Well Casing
<br /> ❑ Domestic/Private C Grave; Pack El Tracy Type of Casing Specifications f
<br /> F' O Public ❑ Other C Delta Depth of Grout Seal Type of Grout--
<br /> -3
<br /> rout �1f6
<br /> )' O Irrigation 1lpprox. Depth d Eastern Surface Seal Installed by S .l ltv
<br /> t Repair Work Done G Type of Pump `` H.P. _ State Work Done �
<br /> Well Destruction D Well Diameter y z ' Sealing Material(top 50'1
<br /> Depth f' Filler Material (Below 50') _
<br /> TYPE-OF SFUIC WORK: NEW INS AL TION :❑ REPAIRIADDITION ❑ DESTRUCTION (No sept!c system permitted if public sewer Is <.
<br /> Q^(fes/N Cr O trO C S' s���� available within 200 feet.)
<br /> Instal(auon will serve: Residence_ Commercial_ Other p LA-C,
<br /> Number of living units! Number o Broom r
<br /> Character of soil to a depth of 3 feet: � y' Water table depth r i yY
<br /> t SEPTIC TANK; Type/Mfg Ca ac'1Y__!_�� No. Cornpartmenta
<br /> (( PKG.TREATMENT PLT.❑ �sy �'S ' �- Method of DisposalVD
<br /> n x.
<br /> ' Distance to nearest: Well i r� Foundation_l Property Line S
<br /> 1 44
<br /> LEACHING LINE ❑ No. & Length of lines —)=X _— gth/six
<br /> Si -M Sill
<br /> FILTER BED O Distance to nearest: Well F anon_ Property Line d'" �+ t�
<br /> VMc
<br /> g SEEPAGE PITS C Depth _ Size Number
<br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line
<br /> 1
<br /> 'SPOSAL PONDS ❑
<br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,-state laws, and '
<br /> r rules and regulations of the San Joaquin Local Health District. ;...
<br /> R,
<br /> ;. Home owner or licensed agent's signature certifies the following:_,;")certify that in the performance of the work for which this permit is Issued,I shell not
<br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature
<br /> i4 certifies the following:"I certify that in the performance of the work for wfiich this permit is issued,I,shall employ persons subject to wurkman's compensa
<br /> 1' tion laws of California."
<br /> The appli nt mu call for all re ui nspecuons Complete drawing on rav' side. '
<br /> Signed 4r i + teaxr t Title:lift- Date:Zs,
<br /> �i
<br /> �' x ;•` FOR DEPAR MENT USE ONLY (,f �-'^ •4� ¢ try
<br /> Date /.._ / J Areo
<br /> Application Accepted by �•�_
<br /> Pit or Grout Inspection by Date Final Inspection by '0_1 Date �'7� ✓4 fxa
<br /> td'* Aoditional.Comments:_� — -
<br /> ❑Stk 466 6781 ❑ Lodi 369.3621 ❑ Manteca 823-7101 racy 835638;;
<br /> Applicant• Retum.all copies to: Environmental Health Permit/Servieoe 1601 . Hazelton Ave., P.O. Box 2009,'Stk., CA 95201
<br /> ,i,•' i
<br /> PEE AMOUNT DUE AMOUNT REMITTED CASH RECE'�VED BY DATF. PERMIYNO.
<br /> NPO _
<br /> ♦EH 112 IREV.10/eal. �s `��- Z`-f`1 I N u ! Y �S �•S . .
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