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y <br /> 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.548 for-sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address 343 MADERA City STOCKTON Lot Size PM <br /> Owner's Name CAL CEDER PRODUCTS -_ Address P.O. BOX 528 STKN, CA Phone 944-5800 <br /> Contractor's Name MRT.D EN K-,- allG No. _x.65_964 Phone 466-0717 <br /> TYPE OF WELL/PUMP: NEW WELL Cl'' WELL REPLACEMENT❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS <br /> INTENDEV USE TYPE OF WELL PROBLEM AREA` CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteµca Dia. of Well Excavation Dia. of Well Casing /f <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications lv <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation — Approx. Depth ❑ E=astern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filier.Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTIONX (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 11 <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'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 oompensation 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 of California." <br /> The applicant must call for all required inspections. Complete drawing on heverse side. <br /> Signed X Title: SECRETARY Date:5-17-84 <br /> t FOR DEPARTMENT USE ONLY r /7^1f T(� <br /> ✓ V <br /> Application Accepted by � � Date � Area //J( <br /> 19 <br /> Pit or Grout Inspection by Date Final Inspection by ,,.)J V- 14 Date <br /> Additional Comments: <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED F. CASH <br /> RECEIVED BY DATE PERMITNO. <br /> + EH 13-241REV.10/93) 414 C [i "1 f7 7L1'-(oo <br /> EH 1426 q <br />