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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 Son Joaquin Local Health District for a penrlit to conetruct andlor Install the work herein described.This application is <br /> made In coritpliance with San Joaquin County Ordinance No.549f0F sewage or No. 18U for we andthe U19f"j!"2r2f the Son Joaquin <br /> Local Health District. �71E ., Rua <br /> 2467 E. French Camp Rd French Camp. 425-323 Parcel C-2 <br /> Job Address City t Size— PM <br /> Owmr'.Name, Ace Tomato to. Address 2771 E; French Camp Rd Phone 982-5691 <br /> Contractor's NarneClark well License No. 371560 Phone 462-7676 <br /> TYPE OF WELL/PUMP: 2 NEWWELL*] WELL REPLACEMENT 0 DESTRUCTION FI <br /> PUMP INSTALLATION El SYSTEM REPAIR 0 OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK 150 1.. SEWER LINES — DISPOSAL FL13.15-0-1 POOP. LINE 151 <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL 50T PITSISUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation 12 51 if Dia. of Well.Casing 6 5/8 <br /> -*t Domeaft/Privale JC Gravel Pack EJ Tracy Type of Casina q t R R I Specifications <br /> 13 Public 13 Other 0 Delta Depth of Grout Sea[ so Type of Grout 9 Back <br /> C3 Irrigation --Approx. Depth 0 Eastern Surface Seal Installed by Clark <br /> Repair Work Dom C1 Type of Pump F;I I h H.P. 1 1 17 State Work Done i ngtal I <br /> Well Destruction 0 Well Diameter Sealing Material (top 50') <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDM ON 11 DESTRUCTION [I (No septic system permitted if public sevver Is <br /> available within 230 feet.) <br /> Installation will areve: 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 0 Type/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT:0 Method of Disposal <br /> Distance to marest: Wall Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED El Distance to merest: Well Foundation Property Lim <br /> SEEPAGE PITS 0 Depth —Size Number <br /> SUMPS 0 Distance to nearest: well Foundation Property Lim <br /> DISPOSAL PONDS 0 <br /> I hereby certilly that I how prepared this application and that the work will be done in accordence with San Joaquin county ordinances,state laws, and <br /> miss and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I cartlify that in the perfortrience of the work for which this permit is issued, I shall not <br /> 'employ any portion in such mannear as to become subject to workman's oompemstion Ism of California."Contractor's hiring or sul>,contracting signature <br /> certifies the follow' 7rll""pt!lo—.nw of the work for which this permit is iss%tecl,I shall employ persons subject to workman's compense <br /> v <br /> tion laws of Ulfr7nia."' <br /> The appli <br /> drawing orl reverse,side. <br /> Signed X04W 11113—Clark Well 4 Oct 1985 <br /> Date: - <br /> IR DEPARTMENT USE ONLY <br /> Application Accepted-by Date ) o Area <br /> a 1. Date, tb-;,l-15 <br /> Pit d(�Impectkm by vuLks-'e, Final Inspection by )A-' 4 <br /> Additional Comments: =,,4PWot ,N , - -_-n sj FhA <br /> 0 Stk 466-Ml 0 Lodi 389-3521 0 ManteciI 82-3-71ch El Tracy i <br /> Applicant-Return all copies to: Envirorlmental Health Permit/Servicas 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95"1 <br /> FEE AMOUNT DUE I AMOUNT REMITTED RECE��ATE PERMIT'NO. <br /> INFC <br /> E�Ism JRw 10tae) <br />