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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) nstall the work . This cation is Application Icompliance wr th Sano the San Joaqu n County OrdinalHealth District for a nce No. 549 for sewage or permit No. 1862 for ewellldpumlp and the Rules and IR Regulations of the San l Joaquin ma ' Local Health District. ' 7531 Caran CityStoekton Lot Size PM Job Address Linzy Cargile Address 7531 Garan Phone '-616 Owner's Name 2Q24 E Charter TATA License No. 3Phone �462— 6 6 Clark well, Inc- Address Contractor -_- - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION l9 SYSTEM REPAIR f OTHER ❑ ' SEWER LINES I DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK , OTHER WELL PITSISUMPS FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Type g e of Casing Specifications - X Domesticl Private ❑ Gravel Pack ❑ Tracy T e of Grout --- ['I Public ❑ Other H Delta Depth of Grout Seal yp ! x. Depth 1 I Eastern Surface Seal Installed by — I I Irrigation —..Appro Repair Work Done L] Type of Pump Sub H.P. State Work Done_ � r ! Well Destruction E) Well Diameter Sealing Material ltop 501 - � r Depth Filler Material I6elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system m permitted if public sewer is s y Installation will serve: Residence� Commercial__ Other } � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depti SEPTIC TANK C1 Type/Mfg Capacity = No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal _ J Distance to nearest: Well - Foundation f "` Property Line * 4 LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑' Distance to nearest: Well Foundation Property Line SEEPAGE PITS l l Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. I Home owns 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 employ-.any rson in such manner as to become subject to workman's compensation,laws of California." Contractor's hiring or sub contracting signature certifies th' fo owing: '9 a ify that in the performs ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o C lifornia."- - i The appl' ust call f r I r- uire in ction Complete drawing on reverse side. Sec--Tres 5 March 90' Signed Title: Date: ..:_ F DEPARTM�E-N�T�USE ONLY Data Area Application Accepted by Pit or Grout Inspection by ate Final Inspection by'"' ` Date i Additional Comments: y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 T - 41"` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazblton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO /�j .,EH 13-24(REV.1/85) I / `� O �d EH 14-28