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APPLICATION huh rtnrvttt <br /> OC�SAN JOAQUIN LOCAL HEALTH DISTRICT �QF S1�k*1T <br /> 1601 E. HAZELTONAVE., STOCKTON, CA R Eff b <br /> �EP\A - Telephone (209) -- <br /> C P�1P�� _I�l� <br /> �OP�N `+` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT 2 5 <br /> oP���EN`�� (Complete in Triplicate) \ <br /> FNVIRONMEY'tC� TAI. q� PP <br /> R r t Irae�WQS) on is,.= <br /> oorr� y made to the San Joaquin Local Health District for a permit to construct and/or install the f the San Jo <br /> S a in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well.pump and the <br /> Local Health District) ` �J <br /> Job Address / r' J City S�.�j�'j/�,u(/ Lot Size PM r/ <br /> Owner's Name <br /> /eDCddress /r �!_✓ —�,�!!.rf/Q Phone <br /> �/1//+ . Gp f F/pec Address / 1 iv License No. <br /> Contractor ! f -!t` d Phone <br /> TYPE OF WELL/PUMP: NEW WEL61l WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLA�TIONSYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ;7—,f SEWER LINES Zf— DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT O <br /> Industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation �.S 7 Dia. of Well Casing ! C✓ <br /> ❑ Domestic/Private PrGravel Pack ❑ Tracy Type of Casing J Specifications <br /> f"l Public fA'Otherl,,"4 l+^ 71 Delta Depth of Grout Seal Type of Grout t ' <br /> I I Irrigation —Approx. D pt I I Eastern Surface Seal Installed by �/✓Rn WGEc,- _ <br /> Repair Work Done L] Type of Pump '.110.11 H.P. 1/7- State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <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 ❑ Type/Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ 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 Property Line <br /> � SEEPAGE PITS I I Depth Size _ _ Number <br /> SUMPS -I Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> T <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 Dihtrict. <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 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 must ca or all rfarr!n � . Complete drawing on re side. <br /> Signed X _ Title: ✓fes/ Date: - <br /> - _ FOR DEPARTMENT USE ONLY <br /> A it <br /> Application Accepted by Date�JI— —_—_ Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: �� hl!jCm k-N&'OL-AhFiAfrZzi <br /> ❑ � <br /> 1 <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-83 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AAMfMOUNT' v D�UE\ AMOUNT REMITTED A RECEIVED BY DATE PERMIYQO. <br /> w ER 13-241REV.11x5) fD,CJ � O <br /> o+ <br /> EN 1426 <br />