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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE ILTON AVE., STOCKTON, CA <br /> i eiepl}orttt (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made4to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> 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 <br /> Local Health District. r <br /> Job Address <br /> 15420 E Highway 4 _ City $tOCkton Lot Size PM ,JREI' DAIRY Address 3754 SOUTH DRAIS ROAD Phone 462-605.2 <br /> OName � I <br /> Contractor's Name <br /> CLARK WELL _ License No. _ 37156Q Phone 462-7676 _ <br /> � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION LX SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - <br /> ❑ Domesticl Private Q Gravel Pack Q Tracy <br /> Type of Casing <br /> Specifications j <br /> f <br />` ❑ Othnr i rl Delta Depth of Grout Seal .__, _....— Typo of Grout <br /> ❑ Public _ 9 � <br /> L7 Irrigation ­­-Approx. Dopth E I Eriatern Surfnco Soal Installnd by--.._.------ •------- ----- <br /> Repair Work done C'1 Typo of Pump P _ State work Done Installed —__ <br /> ._ = _ —� li.P.__"H -- -_—� <br /> We9 Destruction El Well Diameter $fr Sealing Material (top 50'1 ' - <br /> Depth UKN ___ Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> hin retitled if public sewer isava <br /> Installation will serve: 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 ❑ Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Method of Disposal -1 <br /> Distance to nearest: Well Foundation Property Line <br /> R <br /> LEACHING LINE ❑ No..& Length of lines Total length/size r+ <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth' _ —Size Dumber <br /> 111 `SUMPS © Distance to nearest: Well Foundation Property Line <br /> i <br /> f DISPOSAL PONDS ❑ <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, and <br /> f rules and regulations of the San Joaquin Local Health District- <br /> ik <br /> Home owner licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> employ any e n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the oil wing:"I c srtify that in the rforma a of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of`C ifornia.' <br /> The appli n ust call uir in ns. mplete drawing on reverse side. <br /> l Signed <br /> Title: S e C—Tre s Date: - -- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by - ------ _------ - - _.__...__._ <br /> Data__ - 6 - V Area _. <br /> Q <br /> Pit or Grout inspection by <br /> -lam--j - Date t/-0'XrFinal Inspection by Date <br /> Additional Comments: — - --- —- --��--� <br /> ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 D Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Sorvices 1601 E. Hazelton Ave., P.O- Box 2009, Stk., CA 95201 <br /> FEE I CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT ilU1 < AMOUNT REMITTED CASH_' <br /> + EH 13'-24(REV.1011n) <br /> ✓`! �� _ — <br /> EH 142$ <br />