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f SAN JOAQUIN LOCAL HEALTH DiSTRIPT <br /> ksoAl E. HAZEL—i ON AVE., STOCKTON, `j , <br /> Telephohe (249) 466-6781 iy►•ta7� <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED 414:,0 <br /> (Complete in Triplicate) rn . <br /> Application is hereby rnade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> rnada in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Re ulat"o <br /> Local Health District. <br /> Job Address p <br /> " City "'�z"`r'r^kot Size pl1yy <br /> Owners Name Address g, <br /> F>ce7L-7 C �p U <br /> Contractor Address f 1 S -�l S1 if 1 YA <br /> License N Phb�t <br /> TYPE OF WELL/POW. WELL WELL REPLACE ENT ❑ DESTRUCTION ❑ S <br /> ''PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ A5, <br /> DISTANCE TO NEAREST:,SEPTIC TANK "'.306 z SEWER LINES <br /> DISPOSAL FLD. 1-3-00 z -PROP. LINE'�� U <br /> !!FOUNDATION _N�} AGRICULTURE WELL ►� OTHER WELL q PETS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA _ CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ¢Gravel Pack ❑ Tracy Type of Casing G <br /> f7 Fublic Specifications <br /> � <br /> f giber Deltak Depth of Grout Seal ^'G�kt-iL Type of Grout <br /> I 1 trr" ation V <br /> 'g _.Approx. Depth I I Eastern Surface Seal Installed by uC V-4-:4 <br /> Repair Work Done 13 Type of Pump H.P. _�� <br /> State Work Dome _ <br /> Weft Destruction ❑ Well Diameter Sealing Material(top 5o'1 <br /> Depth Filler Material 18elow STI <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I {No septic system permitted it public sewer i5 <br /> available within 200 feet.l <br /> Installation will serve: Rgsidence` Commercial— Ocher r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth• <br /> ❑ Type/Mfg <br /> PKG.TREATMENT PLT.Q Capacity— No. Compartments <br /> Method of Disposal <br /> e• <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines <br /> FILTER BED Total length/size <br /> ❑ Distance to 1learest: Well Foundation Property Line <br /> ti <br /> SEEPAGE PITS I I Depth Size <br /> - Number <br /> SUMPS ' <br /> ❑y: Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑, Property Line <br /> I thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state <br /> rules and regutations of the San Joaquin Local Health Di3trict. taws, and <br /> Home ownerlicensed 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 /> ttmpkly 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 r;ompensa- <br /> tion laws of California." S <br /> Thea lican i <br /> Pp �.r t cat for all r quired i pectians. Complete drawing on reverse side. <br /> Title: Z � _ <br /> Date: ff2 <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date••� �� Q <br /> Area <br /> Pit or Grout Inspection by - p <br /> `;'--�_ "` ..,_. Date 1�es0 Final Inspection by <br /> Additional Comments: 115:r#� 'j !2/ c/G Date <br /> ❑ Stk 466-6781 0 Lodi 369 621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies-to: Environmental Health Patmit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201- <br /> FEE AMOUNT DUE ` <br /> INFO fAMOUNT HEMlTTEO CA N RECEIVED BY DATE PERMIT N0, " <br /> NH 13.24 iREV.tiny <br /> C\1.4.24 <br /> !9 a, . Zz9 <br />