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APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA j <br /> Telephone (209) 466-6781 j <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> Appliin Compliance cation is heie6y made to the San,Joaquin,Local Health District for a permit to construct and/or.install the work herein described. Thts apphcatlonrjs. <br /> Local Health District,with San Joaquin Courity Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of-the <br /> Sari,- in <br /> JoD`Address 3S4i CheriYlnd <br /> i City S I n Lot Size +2 etc ^QS <br /> Owner's Name Italian Athletze C].0 <br /> b4ddress S--e <br /> Phone <br /> Contractor Clark Well, Inc <br /> I Address 202 E. 'Charter Way License No. 377_560�PhoneiA62=767, ":j <br /> TYPE OF WELL/PUMP: NEW WELL EJ WELL REPLACEMENT ❑ DESTRUCTfON L�cx <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. <br /> FOUNDATION PROP. LINE <br /> k AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f <br /> EJ Industrial 0 Open Bottom L7 Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private L"7 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Other i1 Delta Depth of Grout Seal <br /> I I Irrigation „Approx. Depth I 1 Eastern Type of Grout <br /> Repair Work Done ElTypeType of Pump Surface Sea! Installed by <br /> .P. <br /> Well Destruction XR Well Diameter ” <br /> -��- Sealing Material (to State Work Done <br /> � <br /> Depth ' sand re <br /> Filler Material (Below 50'f - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION !l REPAIRJADDITION f I pESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will se rvi: Residence available within 200 feet.1 <br /> Commercial_ Other <br /> Number of living units: Number of bedrooms F 1 <br /> Character of soil to a depth of 3'feet: i <br /> l <br /> SEPTIC TANK CI Water table depth Type/Mfg I <br /> PKG. TREATMENT PLT, LI No.No. Compartments t <br /> Distance to nearest: WellMethod of Disposal f <br /> Foundation Property Line. <br /> LEACHING LINE 0 No. & Length of lines <br /> FILTER BED ❑ DistTotal length/size <br /> Distance to nearest: Well k <br /> Property Line <br /> SEEPAGE PITS I I Depth <br /> Size Number � <br /> SUMPS L� Distance to nearest: Well <br /> DISPOSAL PONDS (] Foundation Property Line <br /> Home owner or licensed agent's signature certifies the foil <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, an <br /> employ any person iner as to o e sub <br /> rules and regulations of the San Joaquin Local Health District. <br /> owing: "I certify that in the performance of the work for which this permit is issued, I shall no <br /> Fryg, manject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature' <br /> certifies the fCa ce that int rma a of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa <br /> tion laws of Calif is <br /> The applicant u 1 f a r qui i i s. Co late drawing on reverse side. <br /> Signed X <br /> Title: Date: 22 Dec 1 M9 <br /> DEPARTMENT USE ONLY <br /> Application Accepted by <br /> l !� <br /> Pit or Grout Inspection by Date Area - <br /> Date Final Inspection by 7 <br /> Additional Comments: Dwell- <br /> ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 <br /> Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 EHazelton Ave.,PSD. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> +.EH 73-24{pEV.1/8 5) PERMIT ND. <br /> 1 <br /> EH 14-2e <br />