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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT ON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES f YEAR FROM DATE ISSUED, <br /> (Completqjnjripficate) <br /> Application is hereby made to the Sari Joaquin <br /> in Local Health District for a permit to construct and/of 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 Hqalth District. ARV.-063-Joe <br /> Job Address Cit,!ge� Lot Size fA CAI'— Pm <br /> Owner's Name VAlay20 1j" JGJ96-S Address Phone$44E&UZ <br /> Ave At" <br /> Contractor g."j,- -4ddfess 1 cerise No.02 Phone I-IAV- <br /> TYPE OF WELL/PUMP: NEW VVEV�)iik WELL REPLACEMENT DESTRUCTION D <br /> PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4n.O-" DISPOSAL FLO PROP LINE <br /> FOUNDATION 10. -t- AGRICULTURE WELLVeA4rOTHER WELL,140- I PITS/SUMPS/46 f- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS <br /> C3 Industrial )-:!;"6pen Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing—,00A044Specifications Wjr-,4 <br /> — <br /> i Public n Other 171 Delta Depth of Grout Seal Type of Gmut 1n6W'L' <br /> I I Irrigation Approx. Depth 111 il(, Easlern relate Seal Installed by (M4C.*A#16e— <br /> Repair Work Done 0 Type of Pump H.P, State Work Donedq4o��,Wp <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I ) INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence P., 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 /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Li No. & Length of lines Total length/size_ <br /> FILTER BED F i Distance to nearest: Weli Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth ­--Size Number <br /> SUMPS L-1 Distance to nearest: WLII Foundation Property Line <br /> DISPOSAL PONDS F1 _0 <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 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."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,Mall employpersons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantjm�!�ll far it d inspections. Complete drawing on reverse side. <br /> Title: _Z Da <br /> Signed X��7� le: <br /> r. FOR DEPARTMENT USE ONLY <br /> ti Application Accepted byDate Area <br /> Pit or Grout inspection by M/11 D'Ite Final Inspection by A;Z1 N Date <br /> 1), -Vv- I <br /> Additional Comments: <br /> 0 Stk 460-6781 El Lodi 369-3621 0 Manteca 823-7104 L) Tracy 835-6385 <br /> Applicant - Return all copies to: EnvironirrIgntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED DY DATE PERMIT"NO. <br /> INFO H <br /> IS r <br /> EH 13.24 MEV.I/M-11 <br /> EH 14-20 <br />