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SAN JOAQUIN LOCAL HEALTH DISTRIP <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. }-� ---TTT--- <br /> Job Address Sot E, G ra t I ne Z2 d. City Lot Size PM <br /> Rooeh SITZ w5 <br /> Owner's Name FCCLC Ifte(saaJ sEleo1rM<Address 1901 I�D� FrGsno GA Phon Ny3-5568 <br /> /' gy52o yls� <br /> Contractoryr Address SO k2 9;60 icense No. 3y�Phone 671 -23g� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f� <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS r7 <br /> 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> till Domestic/Private \'Gravel Pack �(Tracy Type of Casing PV(-- Specifications 1 <br /> 14 teMo l.e Iii <br /> r"1 Pub if 0 Other n Delta Depth of Grout Seal -3 '{2G* Type of Grout <br /> I I Irrigation -2S_3e Approx. Depth 1 I Eastern Surface Seal Installed by YJW4tf- -T 1�Y%A 160 5;,0' <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 teet.l <br /> Installation will serve: Residence_ 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 0 Type/Mfg Capacity No. Compartments <br /> 1 <br /> PKG. TREATMENT PLL Cl Method of Disposal _ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size---- <br /> FILTER <br /> ength/size _—FILTER BED Ll Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS I I Depth Size Number _ \I <br /> SUMPS I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ll <br /> I hereby certify that 1 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 District. <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 no <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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued.I shall employ persons subject to workman's compenss <br /> - <br /> tionlawsofCalifornia." pl.� l1 Div. 44 Grilj.J' 4er TPc 1"'I <br /> The applicant ust call for ell r uired inspections. Complete drawing on reverse side. <br /> Signed X Title: MA n w pg- , S uf�At c Az Date: L <br /> FOR DEPARTMENT USE ONLY �J / <br /> Application Accepted by �4t V � Area <br /> C <br /> Pit or Grout Inspection by Date p coon -_-__ Date <br /> Additional Comments: ��� <br /> 0 Stk 466-6781 0 Lodi 369- 1 0 Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Servicea 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. <br /> INFO r )� <br /> -. EH t}2/(REV.t,.lr fN s/ JZ3 <br /> EH N-2a <br />