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_ 1 <br /> r II r1univ <br /> N JOAQUIN LOCAL HEALTH DIaw <br /> STRIC <br /> 0�OO 1601 E. HAZELTON AVE., STOCKTON, CA . ' <br /> Telephone (209) 466-6781 FES , 1949 U PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENViR01,`'1 "! �,t kit"L1H <br /> PERAAiI I SeRVIGES <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. <br /> �� <br /> Job Address UZC5 zr- Cit, Lot Size pN1 <br /> Owner's Name�iL1f���J /%c � f "44/V1 <br /> AddressPhone to <br /> T <br /> Contractor Address 4 AI` �' Li <br /> cense No. Phone 7�✓ <br /> TYPE OF WELL/PUMP: NEWWELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrialyl <br /> El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Gravel Pack El Tracy Type of Casing ✓ S <br /> ❑ Public Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal ViiNl <br /> ❑ Irrigation p/ r� Type of Grout <br /> rQADprox. Depth ❑ Eastern Surface Seal Installed by CidrNNt N:9 r <br /> Repair Work Done ❑ Type of Pump SteH.P _ <br /> n / State Work Done_ <br /> X�/Well Destruction ❑ Well Diameter Sealing Material (top 50') 7 L _S4iL lase, } fr/ JQ oz. <br /> on rii+ Depth Filler Material (Below 501 � /�}� <br /> TYPE OF SE TIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units:_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments G <br /> PKG. TREATMENT PLL ❑ <br /> Method of Disposal <br /> Distance to nearest: Well _ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well_ Foundation <br /> DISPOSAL PONDS ❑ Property Line <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, 1 shall not <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m t call for all requited inspections. Complete drawing on reverse side. <br /> Signed �gTitle: - <br /> nn _ Date: 211 <br /> C R DEPARTMENT US ONLY <br /> Application Accepts <br /> Date 26 <br /> Z _ Area _ <br /> Pit or Grout Inspection by Data Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 873-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE . AMOUNT DUE AOUNT REMITTED <br /> INf-0 MRECEIVED BY DATE PERMIT NO. <br /> ♦ ER 1124(REV.I/R 5) <br /> EH 1421 <br /> �91RTv, <br />