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11 1 <br /> APPLICATION FOR PERMIT ! <br /> - SAN JOAQUIN LOCAs. HEALTH DISTRICT <br /> HAZELTON ON AVE. STOCICTON, CA <br /> 1601 E. Hsci <br /> fig$ <br /> Telephone (209) 466-6781 9G1 Z g 4HtP� N <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) c��jGG��7 ,1� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de.-? +bed. 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 /> Job Address 32q l r City Lot Size PM <br /> Owner's Name t7je <br /> Address Phone <br /> Contractor .Qdr•'� Address �o�- icense No. �Z Phone+ ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 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 /> ❑ Industrial LlOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> )(Domestic/Private ❑ Gravel Pack .,VLTracy --, Type of Casing Specifications <br /> [I Public C Other YT177-Deka-6 ---T --Depthh of Grout Seal Type of Grout __ W <br /> I I Irrigation _-.Approx. Depth 1.1 Eastern Surface Seal Installed by <br /> `L �4 <br /> S <br /> Repair Work Done Q Type of Pump H.P. State Work Done <br /> _ W <br /> y <br /> Well Destruction ❑ Well'Diametef '��' --* Sealing Material (top 50') <br /> Depth Filler Material IBelow 501 -- <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION (.1 DESTRUCTION I 1 (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 1 Y_ (� <br /> " t� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �` -' U1 <br /> PKG. TREATMENT PLT. ❑ p <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 Property Line <br /> f SEEPAGE PITS i I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <br /> hereby certify that I have prepared this appljcation 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 Dj§trict. <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 /> r employ any person in such manner as`to beco`m'e 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 /> i <br /> The applic 11 for all re fired inspections. Complete drawing on reverse side. <br /> Signe XTitle: Date: Lo' <br /> 4FR DEPARTMENT USE ONLY <br /> I Application Accepted by Date / IP <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by ate / <br /> Additional Comments- <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24(REV.tin5) 3�C, C_ � <br /> t EH 14-26 <br />