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4 <br />SAN JOAQUIN LOCAL. HEALTH DISTRICT <br />1601 E. HAZE. T ON AVE., STOCKTON, CA <br />Telephone (2091 466-6781 <br />PERMIT EXPIRES TYEAR FROM DATE ISSUED `. <br />(Complete in Triplicate) <br />Application is heteby made to the San JoaquinLocal Health District for a permit to construct and/or install the work herein described. This application is <br />or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br />made in compliance with San Joaquin_ County Ordinance No. 549 for sewage <br />Local Health District. <br />Job Address _- 2J T <br />t'f iv,,T R 3:i city Tt c "k +r' r Lot Size rL.l • 1 1y 4i1r icIBM <br />Phone <br />Owner's NameAddress* <br />Contractor <br />;� rV\.t<�1�h Address License No. Phone <br />'%-�YPE OF WELL/PUMP: <br />NEW WELL a WELL REPLACEMENT LJ rata t nuu HUN u <br />PUMP INSTALLATION ❑ � SYSTEM REPAIROTHER <br />❑ <br />Ir- DISTANCE TO NEAREST: <br />SEPTIC TANK SEWER LINES S SAL FLD. <br />PROP. LINE <br />FOUNDATION AGMCULTURE WELL OTHER WELL <br />PITS/SUMPS <br />' - <br />INTENDE=D USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />4 <br />L! <br />L! <br />El industrial <br />ED open Bottom El Manteca Dia. of Well Excavation <br />Dia. of Well Casing <br />L-1 ffomestic/Private ❑ Gravel Pack ❑ ilracy Type of Casing " Specifications <br />f"t Public l7 Other H Delta Depth of Grout Seal Type of Grout <br />i I Irrigation .—.Approx. Q th I I Eastern. Surface Seal installed by2)Y.;.0a <br />Repair Work Done..'itJ Type of Pump '� 4 r7"� H.P. f State Work Done <br />Well Destruction, E3 Well Diameter Sealing Material (top 501 _ <br />Depth Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAtRlADDITION t I DESTRUCTION I I INo septic system permitted if public sewer 151, <br />- available within 200 feet.) ^ _ <br />Installation will serve: Residence _ Commercial _ Other �» <br />Number of living units: Number of bedrooms (L <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK Ll Type/Mfg _ Capacity No. Compartments <br />PKG, TREATMENT PLT. ❑ Method of Disposal <br />Distance to nearest: Well Foundation _ Property Line - <br />LEACHING LINE Cl No. & Length of lines Total length/size _ <br />FILTER BED 0 Distance to nearest: Well Foundation Property Line <br />rn <br />SEEPAGE PITS l I Depth Size Number '{ <br />SUMPSCI Distance to nearest. Well Foundation Property Line ' <br />DISPOSAL 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 />rules and regulations of the San Joaquin Local Health Di§trict. <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, k shaVrlot <br />employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature::, <br />certifies the following: "I certify that in the performanct-of the work for which this permit is issued, I shall employ persons subject to workrhan's compensa--�! <br />tion laws of California.". <br />E The applicant must. call for all requirgd inspections. Complete drawing on reverse side. i <br />l4 s= <br />Title: .: !. ia. ,� Data: •• �" k + t _ <br />+Ikk1 _Signed _•�. - „- <br />EPARTMENT USE ONLY <br />' Date Area <br />Application Accepted by ^ <br />� Imo, � <br />Pit or Grout Inspection by Date Final Inspection by Date 4 <br />. � � .,r b,z �•y-�. ra �, <br />a, <br />Additional Comments <br />❑ Stk 466 -Mt i EI LOdl .�6ri, 3621sp fNanteca a8' 71104_ , l _Tracy $3S-.6385 <br />k' Applicant.= Return,aq ".. le 0" , vhtvhMerltal Health: Permit/Services 1601 E l�axeiton Ave P.O ,Box 2009 Stk , CA�95201��a = r ' <br />. i.x.:T ' F�_e X,�iS%re �.: .�.y.� Kati��si f^t°�'HiaE-�,-a'r' ; ?4 �',a� rs'm.,7}L€F•R�.', <br />'44". <br />Yr <br />''�4"q I ,P,t 4'x } + a; •}_ r j;;. r' eS„t' `' tai'.- - is 3...hKt ,' ;t I t.. n?yrs r-I� i"; �` ,f: <br />t <br />r C: <br />INFO <br />A�r(r f1TCtiUE� a j ?AMou,F1T fiEMITTI:Dk ``. CASH <br />- # � �3x3��1s F� ��' " .i., 1. . ra- .i ,� a. .F— _ .� e;•. 7 F � t 5 �.'rF r�auth �.• i <br />a EH 13-`�9={AEY i H91 "'y f <br />