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SAN JOAQUIN LOCAL HEALTH DISTRIC TN�j - - <br /> 1601 E. HAZE T ON 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 <br /> made in compliance with San Joaquin County Ordinance No. Dis for sewage <br /> to construct and/or install the work herein described. This application is <br /> Local Health District. g or No. 1662 for well/ um <br /> p p and the Rules and Regulations of the San Joaquin <br /> XJob Address S <br /> y City ( Lot Size <br /> \ Owner's Name L-; PM <br /> '-At�ess <br /> Contractor Phone <br /> Address <br /> TYPE OF WELL/PUMP. License No. <br /> NEW WELL ❑ WELL RE LACEM T ❑ Pho�e <br /> PUMP INSTALLATION ❑f DESTRUCTION El �tl Z <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ fit) bt)y1� <br /> SEWER LINES OTHER C <br /> FOUNDATION , AGRICULTURE WELL <br /> --�� DISPOSAL FLD.�r PROP LINE �s <br /> INTENDED USE TYPE OF WELL OTHER WELL <br /> �— PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> f I Industrial E) Open Bottom <br /> { ! <br /> Domestic/Private ❑ Manteca pia. of yyelf Excavation <br /> Gravel Pack L1 Tracy T Dia. of Well Casing <br /> Public ❑ G <br /> I.] Other Type of Casing <br /> I Irrnlahon .GLpt fl Delta Depth of Grout Seal ���� Specifications <br /> r Repair Work Done " APprox. Depth I I Eastern Type of Grout <br /> ❑ Type of Pump Surface Seal Installed by <br /> Well Destruction `�— H.P. <br /> ] Well Diameter State Work Done_ Z - <br /> ---- - Sealing Material (top 50') <br /> TYPE OF SEPTIC WORK: Depth Filler Material (Below 50') <br /> NEW INSTALLAT(ON 1 1 REPAIq/AppITION [ I DESTRUCTION I I <br /> Installation will serve: Residence {No septic system ermined if <br /> Commercial available within 2 P Public sewer is <br /> Number of living units: -- Other 00 feet.} i <br /> Number of bedrooms ------- <br /> soil o1 soil to a depth of 3 f <br /> SEPTIC TANK Pet: �^~' I <br /> rl <br /> PKG. TREATMENT PLT. L] Type/MfgCapacity Water table depth <br /> — -�- <br /> Distance to nearNo. Compartments <br /> est: <br /> -_ Well Foundation Method of Disposal <br /> EACHING LINE "--~— Pr <br /> LTER BED operty Ling <br /> { I No. & Length of lines - <br /> I ) <br /> Distance to nearest: Weft Total length/size <br /> '- <br /> EPAGE PITS Property Line <br /> MPS { I Depth Foundation <br /> Size <br /> POSAL PONDS <br /> I I Distance to nearest: WellNumber <br /> 11 ._`�` Foundation <br /> — Property Line <br /> eby certify that I have prepared this application and that the work will be don ��— <br /> and regulations of the San Joaquin Local Health District. <br /> I owner or licensed agent's signature certifies the following- a in accordance with San Joa <br /> Iy any person in such quip county ordinances, state laws, and <br /> Os the fo}lowin manner as to become subject to wo kman's comp compensation laws of California."Contractor's hirin or <br /> 9: "I certif that in the that in the Performance of the work for which this permit is issued, {shall not <br /> ws of California." y Performance of the work for which this permit is issued, I shall employ <br /> plica must call or g subcontracting signature <br /> a requir d ins p Y Persons subject to workman' <br /> inspections- Complete drawings compensa• +� <br /> on reverse side. ! <br /> Title:�� <br /> FOR DEPARTM NT USE ONLY v Date: if J <br /> on Accepted by <br /> vt Inspection by Date <br /> Date Area <br /> Comments: Final Inspection by C <br /> 6-6781 p Lodi 369-3621 Date <br /> Return all copies to: Environmental Health -71 <br /> Peantemir/Sery ceca 823 s4160t <br /> ❑ Tracy 835-6385 <br /> E. Hazelton Ave., P.O. Box <br /> �. Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CK <br /> 3 {�b, CASk RECEIVED By DATE <br /> J PERMIT-NO. <br />