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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL_TON AVE., STOCKTON, CA <br /> Telephone (209) 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 /> 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. S l"j <br /> Job Address Corher of park & Fifth city Lathrop_ LotSize 5©1X1€/(7' PM <br /> Lathrop County Water District 15755 S 7th 858-4214 <br /> Owner's Name Address Phone <br /> Contractor's Name Clark Well License No. _ "371-5150 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERxx Test Well <br /> DISTANCE TO NEAREST: SEPTIC TANK +100 r SEWER LINES DISPOSAL FLD.-- PROP. LINE 2-E'_ <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL +1(10 t PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing none <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 30d'other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by VX <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <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 ❑ Type/Mfg 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 ❑ 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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent' in s sre 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 ner as to be" subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: "I ce ' that in the pe a ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of lifornia." <br /> The app call r all Ir in cti s mp tdraw' g on reverse side. <br /> Signed itle: —Clark Date: 14 Aug 1985 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDater Area <br /> Pit or Grout Inspection by Date Final Inspection by ' Date U' L ` u <br /> ter. <br /> Additional Comments: D az} <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO.- <br /> INFO CASH <br /> + EH 1344 IAEV,10183) <br /> EH W26 <br />