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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. <br /> Job Address 18846 N Hwy 99 City Lr1d i Lot Size-k 2 O a�^-��g PM <br /> 464 1393 <br /> Owner's Name Victor Fine Foods Address Game Phone46,4 T <br /> Contractor Clark Well Address 2024 F (Ihartc�r License No.�;; � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONx—ic <br /> PUMP INSTALLATION ❑ 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 /> ElIndustrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> `A_ ElDomestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications <br /> .4 ('1 Public Cl Other F1 Delta Depth of Grout Seal _ Type of Grout <br /> a I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by <br /> 1 <br /> Repair Work Done 11 Type of Pump H.P. State Work Done _ <br /> Well Destruction ;k,—>Well Diameter 1611 Sealing Material (top 50') <br /> q� Depth Filler Material (Below 50') ame -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION 1 1 (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 /> 2 Character of soil to a depth of 3 feet: Water table depth \ <br /> p� SEPTIC TANK ❑ Type/Mfg CaPacityCompartmentsNo. ! <br /> tu <br /> PKG. TREATMENT PLT. 11 Method of Disposal �- <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Size _ Number C <br /> SUMPS Ll 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, an <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 <br /> The applica II o all r ire s coons. Complete drawing on reverse side. <br /> (1 Signed X Title: VP ("l a rk We I-1 Date: 3 May 9.0 <br /> �i <br /> FO"EPARTMENT USE ONLY <br /> (, Application Accepted by Date /3�_ O Areap <br /> Pit or Grout Inspection by Date Final Inspection by�? d�/Tr� Date <br /> MAdditional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 10 Manteca 823-7104 Ef Tracy 5 V \ <br /> Applicant - Return all copies to: r ental Heath Permit/ rvices 1 1 E. Iton Ave , P.O. Box 2009 Stk., 95201 ` t <br /> FEE A MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. \x <br /> INFO CASH V <br /> EH1324 IREV.1i M5r <br /> EH 14-29 <br />