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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466=6781 <br /> PERMIT EXPIRES VYEAR 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 1s <br /> sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance Na.549 for <br /> Local Health District. <br /> City STOCKTON Lot Size PM <br /> Job Address <br /> Owner's Name T4 MD_ZZ1K_HUGHES_ <br /> Address 22 STADIUM DRIVE Phone 463-4758 <br /> ' <br /> Contractor Address <br /> License No. 202225 Phone 463-1706 <br /> 1035 s. Auao.RA- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CI <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> f CasingSpecifications <br /> DonlesticlPrivate ❑ Gravel Pack ❑ Tracy Type o <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> [I ❑ Other Public <br /> ❑ Irrigation �J�pprox. Depth ❑ Eastern Surface Seal Installed by vis <br /> H p State Work Done <br /> Repair Work Done ED Type of Pump t/l <br /> Well Destruction ❑ Well Diameter - Sealing Material-(top'501 11 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septi septic <br /> stwitnem pfeettied If public sewer is <br /> Installation will serve: Residence Commercial otherf <br /> k Number of living units: _L_ Number of bedrooms. ` Water table depth <br /> k Character of soil to a depth of 3 feet: 1 <br /> T e/Mt �� Capacity - No. Compartments <br /> SEPTIC TANK � YP g Method of Disposal <br /> PKG. TREATMENT PLT. ❑ i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.'`& Length of lines""""''—' Total length/size <br /> Property Line <br /> I FILTER BED ❑ Distance to nearest: Well Foundation p Y <br /> I <br /> SEEPAGE PITS El Depth 1 Size f Number <br /> I, Property Line <br /> SUMPS El Distance to nearest: Well <br /> DISPOSAL PONDS ❑ i a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sta1-laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 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 became 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 applican ust call for il r -inspections. Complete drawing on reverse side. �O/a/8? <br /> Y AV `t. a � rEiSident Date: <br /> Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date�b �0-7 Area <br /> Application Accepted by <br /> y Pit or Grout In <br /> by <br /> Date Final Inspection by Date" <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 11 Tracy 83ve., 5 <br /> Applicant- Return all copies tq: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.Q. Box 2009. Stk., CA 55201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED SH/ <br /> + EH 13-24(REV.5/e 5) �J �. s <br /> EH 14.26 <br />