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APPLICATION FOR PERMIT <br /> SAN JOAQCiN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. C1 Q 3~�� ! <br /> Telephone (209) 466-6781 !! <br /> DATE ISSUED / — <br /> PERMIT EXPIRES I 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 <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address 800 h ur c Subdivision Name <br /> Owner's NameGDld Bond Building_ ��t�@5tS P. 0. F3Dx '780 Phone 466_�2 51 <br /> Contractor's NameClark Well & EqU License No. '3'71560 Phone _ r <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTIONX <br /> X oV <br /> PUMP INSTALLATION SYSTEM REPRIR Lj OTHER i_j <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 /> F� Industrial U Open Bottom F_� Manteca Dia, of Well Excavation 010 <br /> U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public Other E] Delta Type of Casing <br /> L iirrigation Approx. Eastern <br /> Depth Specifications <br /> ❑ Cathodic Protection Depth of Grout Seal <br /> L7 Geophysical <br /> Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ry A <br /> Well Destructions Well Diameter 1,411 Sealing Material (top 501) �('.ama-nt & lnlatei2�r5--ZaG-k_mix <br /> Depth 921 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j� (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: water table depth <br /> SEPTIC TANK EJ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No, & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number- <br /> SUMPS Distance to nearest: Well Foundation Property Line <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 j <br /> ordinances, state laws, an and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed ent's signa certifies the following: "I certify that in the performance of the work for which this + <br /> permit is issued, 3 hal of employ any rson in such manner as to become subject to workman compensation laws of California." 1 <br /> Contractor's hirin or sub- tracting si t certi es the following: "I certify that in the performance of the work for which <br /> this permit i is ed I s al a loy son s bjec t workman's compensation laws of California." <br /> The applica t e l f r 1 q r d in p on omplete d win n reverse side. <br /> Signed X Title: ark Well Date: 28 Nov 1983 <br /> FOR DE RTMENT USE ONLY <br /> Application Accepted by Area -- ------ (� Stk 466-6781 <br /> Additional Comments: Cj Lodi 369-3621 <br /> Pit or Grout Inspection by Date L_j Manteca 823-7104 <br /> Final Inspection by Date 12-14 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Envi mental Health Permit/Services 1601 E. Hazelton Ave_ P.O. Box 2009, Stk., CA 95201 <br /> FNF <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> r <br /> EH 13-24 REV. 10/82 10/82 50C + <br /> 14-26 <br />