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t � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 permit to construct and/or install the work herein described. 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 33,E City Lot Size UrsaX zSd , PM <br /> Owner's Name ddress / ' f I / �f �/ Phone <br /> Contractor � / SO�c./.5 Address �V . (,tJ;Z5-- / 'cid t License No.A5 1911 Phone �0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing W <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout-Seal °'r Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ' <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Belo>—%') <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 'available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> CIA, <br /> Number of living units: _J_ Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: SAN t L A Water table depth <br /> SEPTlC TANK Lif' T e/Mf C o ` ��6d G' <br /> YP g Capacity` A No. Compartments <br /> PKG. TREATMENT PLT. ❑ k} Y`r Method of Disposal +� <br /> Distance to nearest: Well 7-6 Foundation- '.3O Property Line _30 / <br /> 1 <br /> f <br /> LEACHING LINE No..& Length of lines -� _ _ i*. "�"" T--al length/size-. <br /> FILTER BED Distance t6 nearest: Well Foundation!< Property Line <br /> SEEPAGE PITS ❑ Depth Size _ Number <br /> SUMPS ❑ Distance-to oearest:— ---Well--- FounJation —.�'-` Property�Line <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that I 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 District: <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 applica ust call or all requ ed ins ctia . Complete drawing on reverse side. �yy� / Q <br /> Signed Title: _1111"_p —+>-v� ea _ Date: 12 U Q <br /> FOR EPARTMENT USE ONLY .r <br /> Application Accepted b Date -/4 Area 04 <br /> 7 <br /> Pit or Grout inspection y /,A Date - Final Inspection by � �/ ! Date ps � <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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO.' <br /> 1� <br /> + EH 13-24(REV <br />