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APPLICATION FOR PERMIT <br /> x SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA SCANND11 <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br />µ lication 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 /> App' <br /> t made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 1M East of Cambridge ,, 2Q01 N Of CityLathrop Lot Size PM <br /> Job Address Ming o <br />� Owner's Name <br /> WSP Address 1022 Woodland Ave Modesto Phone 523-56i. <br /> Contractor Clark Well Address <br /> 2024 E Charter Water License No.-371560 Phone 462 '7676 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION � 1 . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR [J OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r <br /> ❑ Industrial EJOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> T e of CasingSpecifications <br /> ❑ Domestic/Private 1-1 Gravel Pack ❑ Tracy yp g Type of Grout <br /> P Public 1-1OtherF-1 Delta Depth of Grout Seal yp <br /> I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> til Well Diameter I Sealing Material (top 50'1 �.'ement <br /> Well Destruction I ; <br /> Depth —�< _ Filler Material (Below 50') Cement <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION €:I REPAIR/ADDITION i I DESTRUCTION I I iNailabetrwihisyst em 200 f permitted if public sewer-is <br /> Installation will serve: Residence "_ ,Commercial— Other <br /> i <br /> Number of living units: Numbe`r of,bedrooms x <br /> Water table depth—E�E <br /> Character of soil to a depth of 3 feet:. / <br /> SEPTIC TANK ❑ Type/Mfg "' Capacity No. Compartments <br /> PKG, TREATMENT PLT. Elii �, 7' Method of Disposal Ai <br /> Distance to nearest: all Foundation ,Property.tine <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to neatest:µ Wefl Foundation Property Line <br /> Number".: r- <br /> . <br /> l SEEPAGE PITS i I Depth "`"'t r Size; t t <br /> t f <br /> ❑ Distance to nearest: }Well Foundation Proi)erty Line <br /> SUMPS <br /> ? <br /> DISPOSAL PONDS ❑ <br /> G will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work <br /> rules and regulations of the San oagwn Local Health District. <br /> .� �- <br /> Home owner or licensed agent's rgnattire certifies i ie flowing3 "i certify that in theperfo�manI f of fhe work Vfo>r winch this permit is issued) 1 shall not <br /> employ any rson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies th f Ilowing: "I certify that i e perf ance of.the work for which this permit is issued, <br /> I shall employ persons subject to workman'scompensa <br /> tion laws liforni � <br /> The applica must c f re i d i c s. Cortlpleta drawing on reverse side. <br /> ` . Sec-Tres Date: 9/1.2/88 <br /> Signed <br /> r Title: <br /> i <br /> FOR DEPARTMEAtT USE ONLY <br /> Date Area i <br /> Application Accepted by JL <br /> If <br /> Pit or Grout Inspection by <br /> Date Final Inspection by��� Date !u <br /> Additional Comments: _ <br /> I —`❑Sik °'466=6781'"`"�. ❑ Lodi-369.3611--❑ M9nteca,�823:710T` ❑ 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 /> IFEE <br /> NfO AMOUNT DUE AMOUNT REMITTED CASH =HEIVEDY PATE PERMIT NO. <br /> +.EH 13-21 triEV.s/x 51 <br /> EH 1428 <br />