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'._ <br /> ' APPLfCATION FOR PERMI <br /> -4:SAN JOAQUIN LOCAL HEAL H�DIS`TRI .� <br /> 1601 E. HAZELTOM'AVE., STQCKTON, G <br /> �o Telephone (209) 466-t7$1 <br /> X <br /> 1 PERMIT EXPIREP 1 YEAR FROWDATE ISr UED' - <br /> (Complete in Triplicate]l <br /> s. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/dl - Mall the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welfl0tand the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Add ftd .- P city F Lot Size PM <br /> Owner's Na Address s4 '' Phone <br /> /"Contractor " 0TVi ♦M. . <br /> ��� Address License No.0�1 Phone S-1 <br /> TYPE OF WELL/PU NEW WELL ❑ WELL RE ACEMENT,-El 1 DESTRUCTION ❑ <br /> 1� PUMP INSTALLATION ED SYSTEM REPAIR.,E] pTHER O <br /> DISTANCE TO NEA ST:,.SEPTIC TANK SEWER LINES6� DISPOSAL FLD, PROP. LINE w <br /> '*1i0UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE .-TYpi OF WELL 1'1 IZOBLEM AREA CONSTRUCTION SPECIFICATIONS' <br /> %,. <br /> ❑ Industrial i }17`Open,Bottom ❑ Manteca Dia. of Well Excavation ' Dia- of Well Casing r <br /> ❑ Domestic/Private ❑ Gr Pa EJ Trac <br /> hype of•Casing ° Specifications <br /> I] Public ❑ Ooh + Delta . bepth ofGlout Seal Type of Grout ] i <br /> El Irrigation ox.'Deptlr171 Eastern' Surface Seal Installed by <br /> i <br /> Repair Work Done ❑f Type pw H.P. = State Work Done <br /> Well Destruction ❑ Weil^bia SealinghA�te ial�ftop 5d'1 - w <br /> Depth + •�` ,,Filler Materrial (Belo_w 50') <br /> TYPE OFL SEPTIC WORK: NEW INSTAL TI N ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �` ava0able within 200 feet.► .♦' <br /> %Installation will serve: Residence= Yf <br /> ommt rclal Other- } <br /> Number of living units:, Number bedrooms <br /> Character of soil to a depth of 3 feet: <br /> _ p V4later table depth <br /> SEPTIC TANK I]'� e/Mf r ' <br /> YP 9 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �� � Method of Disposal ` 4i <br /> Distance to nearest: ` WE3ll r Foundation 'Property Line <br /> LEACHING LINE No. & Length of IiFI®5 L[=' 10 Total length/size f <br /> FILTER BED ❑ Distance to nearest: elft n Foundation Q Property Line___ ,.j <br /> 0 SEEPAGE PITS ❑ Depth .e. .` ze Number <br /> SUMPS ❑ Distance to nearest, Well `Foundation i Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application"Ind that the work will berdone'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:"Cceitify 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 cal gr 8`17ired im pections.'Complete drawing on reverse side. <br /> Signed X Title: Dater <br /> ♦ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 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'W6. +� <br /> a INFO CASH <br /> + EH13-24(REV.1/65) 'eg ---'�Q`• �. `- f - <br /> EH 14 <br /> f <br />