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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 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 described.This application is <br /> i 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 /> y Local Health District. <br /> 1905 N . Broadway Stkn app '5 acres <br /> Job Address City Lot Size PM <br /> Brea Ag 1905 N Broadway 466-5911 <br /> Owner's Name Address Phone <br /> Clark 37,1560 462--7676 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 3Q t 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Re ai ❑ Type of Pump H.P. State W rk Done <br /> Well Destruction Well Diameter �5 7/811 Sealing Material (top 50') S a C K m i X a n 8 fn a n- ' <br /> Depth Filler Material (Below 50') Same <br /> TYPE OF SEPTIC WORK,: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 ❑ T e/Mf <br /> yp 9 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED IDDistance to nearest: Well Foundation Property Line <br /> k <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Weli Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and tliat 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."Contractors hiring or sub-contracting signature <br /> certifies the following:"I t ormancof the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cal' rnia' <br /> The applican 6 t II f all (A*e <br /> omplete drawing on reverse side, <br /> r signedVP Clark Well &. Equipment 30 Dec 1987 <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 7 G-4- / Area <br /> j <br /> Pit or Grout Inspection by Date Final Inspection by = Date Cl� <br /> Additional Comments: _ �— I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823f7104 ❑ T acy 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 AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT"N0. <br /> INFO CASH <br /> + EH 183 <br /> 24(REV.101 <br /> W <br /> EH 1426 <br />