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� •f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 4777 East Carpenter Road city Stockton Lot Size PM Owner's Name Siebert Trailers Address 4777 E Carpenter Road Phone 465-7264 Contractor Clark Well, Inc. Address 2024 E Charter Way License No.371-560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION ❑ SYSTEM REPAIR EX OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public D Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _._Approx. Depth I I Eastern Surtace Seal Installed by �I Repair Work Hone ❑ Type of Pump Sub H.P. i 5 State Work Done Replaced Well Destruction ❑ Well Diameter Sealing Material (top 50'1 �- Depth z Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLA —REPAIR REPAIRIADDITION1 1—DESTRUCTION-1-1-(No'-septic"system pefmitted if public sewer is � J available within 200 feet.) Installation will serve: Residence Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet, Water table depth SEPTIC TANK ❑ Type/Mfg1i Capacity No. Compartments', J I PKG. TREATMENT PLT. ❑ F t t �. --,,--,,-Method of,Disposal Distance to nearest: Well ._.'' Foundation Property Line , LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ t SEEPAGE PITS 1 l Depth Size Number SUMPS Ll Distance to nearest: Well { Foundation F 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 reg a ns of the San Joaquin Local Health District. Home owne or ii ensed is signwing: "I certify that in the performance of,the-wo"rk for which this permit is issued, i shall not employ any erso in su h n r aworkman's compensation.laws of California." Contrac'tor's hiring or sub contracting signature I certifies the oir no; " certif at he work for.which this permit is issued, I shall employ persons subject to workman's compensa- tion laws ►^ t4 The applicate drawing on rse side. Sec-Tres . ./16/89 u Signed X-"=— Title: Date: FOR DEPARTMENT USE ONLY ` Application Accepted by Date �/ Area 2/ ` Pit or Grout Inspection by Date Final Inspection by Date } Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � i FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY `DATE PERMIT'NO, +.EH1 -21tREV.1 H5r 4 EH 11-2t3 { Y