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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> k sr <br /> 1601 E. 'HAZEL—i ON AVE., STOCKTON, CA RECEIVED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F E B 02 1990 <br /> t <br /> ' (Complete in Triplicate) SAN JOAQUIN (',0LIN T Y <br /> n'Ipp� �� <br /> Application is hereby mlicdtion is <br /> ade to the San Joaquin Local Health District a <br /> ' fpermit to construct and/or install t`tt¢'dv 0 n Joaquin <br /> [ made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump� �� <br /> Local Health District. 1 <br /> 3400' WEST OF C/L OF JACK TONE ROAD <br /> Job Address ENIA NIA <br /> 40' NORTH OF C/L OF LIVE OAK ROAD City COUNTY Lot Size PM <br /> AST BAY��MUNICZPAL P.O. BOX 24055 <br /> UTILITIES 'DISTRICT Address OAKEAND CA. 94623 Phone (415)835-3000 <br /> Owner's Name 415) <br /> AMERICAN OONSTRUCTION 1038 REDWOOD HIGHWAY, SUITE 2 E <br /> Contractor AND SUPPLY; INC. Address MILL VALLEY CA. 94941 License No. 310599 Phone 381-0838 <br /> ° TYPE OF WELL/PUMP: i�l NEW WELL _ WELL REPLACEMENT C] OTHER <br /> ❑ <br /> i <br /> PUMP INSTALLATION ❑. SYSTEM REPAIR 1:1 <br /> OTHER ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK N/A SEWER LINES NA DISPOSAL FLD. N/A PROP. LINE __NLA_ <br /> FOUNDATION N/A AGRICULTURE WELL NIA OTHER WELL N/A PITSISUMPS 1_v�A G <br /> INTENDED USE TYPE OF WELL \ PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> pDia. of Well Casing N/A <br /> L] Industrial 4 ❑,Open Bottom .•-f,❑ Manteca Dia. of Well Excavation <br /> -r t — NONE Specifications <br /> ❑ Domestic!Private Ll'Graver Pack ❑ Tracy• Type of Casing— <br /> FI <br /> f'1 Public 5 -XXOther Cl Delta Depth of Grout Seal 195' Type of Grout SAND CEMENT <br /> I Irrigation 300.1. . ). . Depth I I Eastern %_'Surface Seal Installed by TREMIE METHOD ` <br /> Repair Work Done LJ Ty e of Pump i H.P. State Work Done <br /> tt <br /> Well Destruction ❑ Well Diameter 0 Sealing Material (top 501 <br /> r CATHODIC PROP. Depth 3 '1 <br /> .00' Filler Material IBelow 50 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I l iNo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> ti <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: iM Number of bedrooms <br /> Character of soil to a depth of 3 feat: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments <br /> j PKG. TREATMENT PLT. ❑ : Method of Disposal <br /> r <br /> Distance to nearest: Well Foundation Property Line t <br /> { LEACHING LINE ❑II No. & Length of lines i Total length/size <br /> FILTER BED _ 4 Distance to nearest: Well T Foundation Property Line }° <br /> SEEPAGE PITS l I� Depth Size Number <br /> r <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 ISan Joaquin Local Health Diktrict. <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 issuod, 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: '9 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." I l <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Lh STEVE MCKIM Title: PROJECT' MANAGER 1/22/90 <br /> Signed X AAZ <br /> Date: <br /> 0011 IF R DEPARTMENT USE ONLY <br /> Application Accepted by Data ��— Area <br /> -Pit or Grout nspection by <br /> Date 3- �'�L� Final Inspection by Date <br /> Additional Comments: III <br /> ❑ Stk 466-6781 C1 Lodi 369-3621 ElManteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P1.0. Box 2009, Stk., CA 95201 <br /> 4 <br /> FEE #M�OUUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> k <br /> +�EH13241REV.t/n51 � � ��� <br /> EH 14-26 <br />