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41 <br /> APPLICATION FOR° PERMIT <br /> ,,,SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 5 oaquin Coun Oge or No. 1862 for well/pump and the Rule <br /> r Finance No. 549 for sewas ^flulon t� i Joaquin <br /> Local Hea m y <br /> Job Address Sharo2 Army Depot City Lot size PM <br /> Riede Construct ion liililYlAddress P'.0• Box 107, Woodbridge Phoneq�3 <br /> Owner's Name ' <br /> - 3525 Pelandale,. Mod. License No290813 Phone 545-1185 <br /> Hennings. Bros. Address . <br />,r..'a• . <br /> Contractor 9 <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT 1:1DESTRUCTION <br /> ":•�. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1� <br /> = FOUNDATION: AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> e NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> . Dia. of Well Casing <br /> ❑- industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g <br /> >a- Type of Casing Specifications <br /> CI f]amestrc/,Private ❑ Gravel Pack ❑ Tracy 9 <br /> Type of Grout <br /> f l Put'Vic. ^ . N �I71 Other n Delta Depth of Grout Seal <br /> € I Irriatiori Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair WDrkQpne ❑ 'Type of Pump p H.P. State Work Done _ <br />` Well Destruction XX Well Diameter 14411Sealing Material (top 50') <br /> 1 Depth aprOX':__300t Filler Material (Below 541 ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION (.1 DESTRUCTION I I (No septic <br /> systhin m retitled if public sewer is <br /> available I Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> I Character of soil io 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 /> 6 <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i SEEPAGE PITS I I Depth Size — Number <br /> SUMPS 0 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 Di§trict. <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 signatur <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 California." 4 <br /> The applicant must call for all,required inspections: Complete drawing c r arse i <br /> Rennins Bros. Title: t Date: 10-17-88 <br /> Signed X FOR DEPARTMENT USE ONLY <br /> A <br /> Application Accepted by ate ' data � Area <br /> l Pit or Grout Inspection by n by Date <br /> Final Inspectio ( 5 <br /> r <br /> Additional Comments: �� t4- c& 1 is <br /> t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca d3-71M ❑ Tracy 835-6305 U <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y <br /> FEE TTED AMOUNT DUE - A OUNT REMICASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +-EH 13-24MEV.1/K5) <br /> EH 14-2a <br />