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a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> + 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES YYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sail 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. <br /> 20 acres <br /> 4980 E. WoodbridgeRd ACam <br /> Job Address City poLot Size PM <br /> Marvin Mayer same 369-0577 <br /> Owner's Name �' -•-- Address Phone <br /> Contractor Clark Well Address 2024 E. Charter License No. 371 560 Phone 462-7676 <br /> TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT ❑ DESTRUCTtON_-�Ek <br /> PUMP INSTALLATIONKCK SYSTEM REPAIR © OTHER ❑ <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other 1-1 Delta , Depth of Grout Seal Type of Grout <br /> I I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump Sub H.P. 2 State Work Done n__Sta1 1 <br /> n <br /> Well Destruction Well Diameter 6 Sealing Material Itop 501 sack <br /> Depth naFiller Material {Below 50'1 n rr <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system 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 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line (� <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> - <br /> SEEPAGE PITS I 1 Depth Size _ Number , <br /> SUMPS D 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 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 persons subject to workman's compensa- <br /> tion laws of Californi .' <br /> The applican s all f ail a ire In cti- s. ompl drawing on reverse side. <br /> Signed Title: <br /> VP Clark Well Date: 8 Nov 88 <br /> x <br /> -0.. <br /> FO DEQ&�MEfNT-USE ONLY <br /> Application Accepted by �'- � Date '�" Area <br /> Pit or Grout Inspection by Date Final Inspection by /Zi Date l V3—E Sr <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 ? _ <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK C SH RECEIVED BY DATE PERMIT'NO. f <br /> INFO <br /> 3 v Ry (pep- :;b6+ EH 13.24IRfV.tiK51 ,J d � <br /> EH 14-2a d. }-- <br /> 7�.M 1 flt o + <br />