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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE:.i ON AVE.. STOCKTON, CA <br /> Telephone (209) 48fi-8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicates <br /> Application is hereby made to tlhe San Joaquin Local Health District for a permit to o cons tar %gridjor wmin&t&K the arhd the Rules <br /> r hatain and fiaq Vib6d. 1 the Joaquin <br /> ,da in canwI4 tnca with San Joaquin County Ordinance No.M9 la Irwaga 00 <br /> Local Health Drsaict- <br /> t <br /> Jab Address City Lot Sits PM <br /> Q 9 c <br /> Orrnor's Ida Address Phone <br /> Cattractor Address �R"i r License Ho <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION p <br /> PUMP iNSTALLATION ❑ SYSTEMS REPAIR L] OTHER ❑ t <br /> 01STANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION -- AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cf Indus hol ❑ Open Bottom ❑ Manteca Diar. of Well Excavation Die. at Well Casing <br /> L7 Ownesticrrptivats ❑ 64,"Pack C1 Tracy Type of Casing Specifinatioru <br /> i'I Public f 1 Olher t-) Delta Depth of Growl Seal Tyree of Grout <br /> r I lnrgation —Apptort. Depth r I Eastern 5urlace Simi Installed by <br /> Repsit Work Done 11 Type of Pump N.P. — State Work Done <br /> Well Destruction f"i Well Diameter Sualinp Malarial Itop STI <br /> Depth FNIer Material i9alow Uri <br /> TYPE OF SEPTIC WORK; NEW INSTALLATMN REPAIR ADD17tON I I DESTRUCTION I : INo seplic system permitleej it ptil*C sswel is `• <br /> - r�— available within 200 fees,l <br /> In"aWn writ serve: Residence COf kr'W faL, Oltm. <br /> Number of living units: Number of - - &171 <br /> Character of soil to a depth of 3 feat Water (able depth <br /> SEPTIC TANK ufTypelMfg d — Capacity 0 No. Conhpattrnsrits <br /> PKG. TREATMENT PIT.LJ �w�.�yf� 1/ Syr, i M Ood of Disposal <br /> Distance to nearest. Wail_ Foundation 0 Rrapertlr Line.6-s — <br /> LEACHING LINE f Ho. A Length otimvw��l <br /> �nTotal lsngth/seal _ <br /> FILTER BED 0 Dimanca w nearest: Wail Foundation 4 PropmtY L&la <br /> SEEPAGE PITS i 0-15epth �. Slttr Number - <br /> SUMPS t I Distance to nearest: Weft 'Fovndalian r Property I-a* <br /> DISPOSAL PONDS Cl ' <br /> I hamiliv certify that I have prepared this application and that the work will to done in accordance with San Joaquin►courtlY ordinances, State(awl, and <br /> rules dnd regulations 01 the San Joaquin Locei Health District- <br /> Horne owom or licensed agent's signature cattifisS this lollorving: "1 certify that in The p*rfpr=nce of tha wort fly which this permit is issued,1 shaa not <br /> employ any person in such msrtrwr AS to become Subject to workman's eonVensation laws of California."Contractors hiong at sutreontracting signature <br /> certlims the loaovikV: 1-1 cortily that in the per famw noe of N+*work far which this parrnit is iesuo.I shall employ persona sublact to warkmari a compensa- <br /> tion laws of Calilarrtia." <br /> The applicanLmwt call!or rerquirad inspections. Complete drawing on verse Srde. <br /> Signed x —- Titer. Dale: <br /> FOR DEPARThIlW AI$E OILY- •- - -• <br /> Application Accepled by V Date -- Area <br /> Pi Grout inspection by q Final Inspection f] �� <br /> 6 <br /> AdditlorW Comn►snta: <br /> U1 Sik I6&6781 ❑ Loch N9.3621 ❑Abntece 833-7104 ❑ Tracy 8354M <br /> Applicant-Return all copier to: Envifonaronlal H*dth ParntirlSe Vv m 1il I E. Ha:elton Ave., P.Q. Bea 20pS, 51kk�.. CA 952D1 <br /> FEE AMOUNT DUE AMOUNT REWTTEC C5H RECOVED BY OATc P€RMII No, <br /> LNFG <br /> . V U-N(REV %I M ar I�� / <br /> EH 1&Is <br />