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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 /> Applicin ation 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 a <br /> made compliance with San Joaquin County Ordinance <br /> Local Health District. m <br /> No.549 for sewage or No. 1862 for well/pup and the Rules and Regulations of the San Joaquin <br /> � <br /> Job Address 1 1 th Se uol.a <br /> 1 City Tracy Lot Size PM <br /> Owner's Name Alden Company 411 Borell Ave. Suite 605 <br /> AddressPhone 415-571 -14 1 <br /> Contractor's Name Clark Well & Equip q p License No. 371560 Phone 462-7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION ❑ SYSTEMDE57RUCTIOREPAIR El OTHER R Ell <br /> DISTANCE TO NEAREST: SEPTIC TANK El LINESDISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 0Manteca4 <br /> Dia• of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack <br /> ❑ Public ❑ Tracy Type of Casing Specifications <br /> ❑ Other <br /> ❑ Delta Depth of Grout Seal , <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern <br /> Repair Work Done EJ Type Surface Seal Installed by Type of Grout <br /> of Pump <br /> WeH.P. State Work Done <br /> WellDestruction ElWelllDiameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence, Commercial, Other available within 200 feet.) y.?' <br /> Number of living units: Number of bedrooms !l <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE L7 No. & Length of lines <br /> FILTER BED Total length/size <br /> ❑ Distance to nearest: Well- Foundation <br /> i Property Line <br /> SEEPAGE PITS <br /> ❑ Depth Size <br /> SUMPSNumber <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 shall employ <br /> tion laws of California." p p y persons subject to workman's compensa- <br /> tion <br /> applican (s II or uir d spections. Complete drawing on reverse side. <br /> Signed 'VP— Clark Well <br /> Title: Date: 19 <br /> �R A ENT USE ONLY <br /> Application Accepted by �/ <br /> Date e j <br /> Pit or Grout Inspection by Date <br /> Final Inspection Date <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ 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 AMOUNT DUE CK# <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE <br /> PERMIT'NO. <br /> EH 1324(REV.10/83) <br /> EH 14-28 <br />