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APPLICATION FOR PERMIT <br /> SAN JOAlaUIN 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. <br /> Job Address 4708 Hogan) Lane City Lodi Lot Size PM <br /> Owner's Name PMA REALTORS — Address 1151 W Robinhood #21B Phone 477-8700 <br /> Contractor Clark Well Address 2024 E Charter Way License No. 371560 phone 462-7676 <br /> TYPE OF WELL/PUMP: (NEW WELL D WELL REPLACEMENT El DESTRUCTION 0 <br /> PUMP INSTALLATION Ll <br /> SYSTEM REPAIR OTHER C1 <br /> _-__DISTANCE_T.P.NEAREST. SFII <br /> SEWER LINES DISPOSAL FLO.— PROPALINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS <br /> INTENDED USE TY-RE.OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial Ll Open Bchtom 4 11 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private C-1 Gravel Pack—,-LI.,Iracy Type of Casing Spec�ification I s <br /> Public Cl-'OtherJi 71 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _ <br /> _Appto�. Depth � I Eastern Suriace Seal Installed by <br /> ff Repair Work Done El Type of Pump SUb H.P. Utl State Work Done -2um p Repair <br /> Well Destruction LJ Well Diameter- Sealing Material {top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 1`1 FPAIR/ADDITION I I DESTRUCTION I I INo septic system-permitted if public sewer is <br /> 14—­.4, - , -- , .--- - ­­1 available within 200 feet.) Dl� <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 /> 7— <br /> SEPTIC'TANK C1 Type/Mfg <br /> Capacity— No. Compartments <br /> PKG. TREATMENT PLT. Ll t Method of Dispo'sal; <br /> is Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines r Total length/size <br /> FILTER BED I — <br /> D Distance to nearest: Well Foundation-�_ __ _Property Line <br /> SEEPAGE PITS 1. 1 Depth —Size Number A i <br /> SUMPS - 1 1 <br /> U Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS Ll <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 ownerlicensed agent's signature certifies the following: "I certify that in the performance of the work for which this per J mit is issued, I shall not <br /> ,,employ any , on i in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies theloll wing:" entity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion <br /> k <br /> tion laws o C fornia. <br /> I ir <br /> The ppliclanust call uir tion4omptate drawing on reverse side. <br /> Signed X LLA JLA-P-VL Title: Sec-Tres Date:1:0/25/88 <br /> ts <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ate <br /> Area <br /> Pit or Grout Inspection by Da(J <br /> Final Inspection by Date <br /> Additional Comments: <br /> D Stk 466-6781 0 Lodi 369-3621 11 Manteca 823-7104 LJ Tracy 835-6385 <br /> Applicant - Return all copies to: Envir6nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS. RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> EH 13-24(REV.riH 5) f7 <br /> EH 14-28 <br />