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'i APPLICATION FOR PERMIT <br /> PS <br /> r F, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R 1601 E. HAZELTON AVE., STOCKTON, CA W <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. v <br /> l4?35 DATE AVE. city STOCKTON Lot Size PM <br /> Job Address <br /> - . .. same � . - 463_1150 <br /> Owner's Name <br /> MILLER MORGAN Address Phone <br /> 202228 Phone 463_1706 ` <br /> y Contractor <br /> VETTER PLBG. CO. A��►1035 S. AURORA ST- License No. r—t <br /> II TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> [ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # <br /> ❑ Industria! <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1 Specifications <br /> Grout❑ ❑ Gu <br /> ❑ Domestic/Private Gravel Pack <br /> Tracy Type of Casing Type of rvt <br /> 1-_1 Public Other El Delta Depth of Grout Seal { <br /> ❑ Eastern Surface Seal Installed by <br /> ED Irrigation ---Approx. Depth <br /> Repair Work Done ❑ Type of Pump <br /> H p State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> 3 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONA <br /> a o septitic sy tem permitted if public sewer is <br /> k Installation will serve: Residence_ Commercial Other <br /> r 1 w <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Gapacity. a No. Compartments <br /> SEPTIC TANK Type/Mfg <br /> J <br /> Method of Disposal <br /> PKG. TREATMENT PLT- F] t <br /> fFoundation€ i Property Line <br /> I Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ No. K Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation VProperty Line <br /> SEEPAGE PITS LlDepth Size Number w T <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Lin <br /> DISPOSAL PONDS ❑ <br /> 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 sfia11 employ persons subject to workman's compen58 <br /> tion laws of California." ° <br /> The applicant ust tail for all requir d in ions. Complete drawing on reverse side. 3�18�87 <br /> Signed x <br /> (: � Title: PRESIDENT Date: <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by �7 y7 <br /> Pit or Grout Inspection <br /> Date Final inspection by - Dat U / <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 <br /> -6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk,, CA 95201 <br /> FEEK RECEIVED BY DATE PERMIT`NO. <br /> t INFO AMOUNT DUE AMOUNT REMITTED G <br /> + EH 13-24 1REV.ti/a 51 <br /> EH 1428 <br />