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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZEL T ON AVE:; STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> is <br /> Application is hereby made to the San Joaquin Local Health fo`fpermit sewage o°construct. 1862 for well tlpump and the Rules/or install the work and Reg a6rein ons of the Se-This 'J qu <br /> in <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. „ <br /> Job Address <br /> 1965 SUNSET City STOCKTON Lot Size PM <br /> 1661 STONECREST RD. PhoA16 626-3557 <br /> Owner's Name BERNARD REISCHMAN Address pI,ACER.VILLE, CA. 5 <br /> VETT ER PLBG. CO. Addre111035 S• AURORA ST. License No. 20_228 .Phone463-1706 <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <br /> SYSTEM REPAIR ❑ 0THE -❑ <br /> PUMP INSTALLATION ❑ DIS <br /> SEWER LINES PO PROP. LINE <br />_ DISTANCE T EST: SEPTIC TANK � PITS/SUMPS " <br /> UNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE QF PROBLEM ONSTRUCTION SPECIFICATIONS <br /> nteca Dia. of Well Excavation Dia. of Well Casing ` <br /> El industrial ❑ Open Bottom Specifications <br /> ❑ Tracy Type of Casing <br /> ❑ Domestic/Private 17 Gra Dept Grout Seal Type of Grout <br /> ❑ Public Other ❑ Delta <br /> ik <br /> ---Approx. Depth ❑ Eastern Surface Seal <br /> [3 Irri ati In <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction [I Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501 } <br /> PE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIR/ADDITION ❑ DESTRUCTION aNailabpekwthm 200 feet.) h public sewer is <br /> TY �����Lu <br /> Installation will serve: Residence; Commercial Other '`�'q ""� � <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ,< Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Line <br /> Distance to nearest: Well Foundation Property <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED El Distance to nearest: Well Foundation <br /> r ❑ Depth Size Number <br /> SEEPAGE PITS Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <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, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> l not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the <br /> laewsoof Califorrnia."Contractor's nce of the work for lhir hiring or sub-contracting signature <br /> employemploy any person in such manner as to become subject to workman's compensationM� <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 st call for all r inspections. Complete drawing on reverse side. 2/27187 <br /> Title: PRESIDENT Date: <br /> Signed <br /> L FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Acceptedby - <br /> i Pit or Grout Inspectio Date <br /> Final lnspectian Date <br /> i <br /> 4 Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CASE{ RECEIVED BY DATE p PERMIIT]NO. <br /> INFO <br /> + EH 13-24(REV.1/65) ✓ �� ���� <br /> EH 14-28 <br />