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APPLICATION FOR PERMIT <br /> SAN JOAQUINIOCAL_HEALTH DISTRICT <br /> 1601 E.MAZELTON.-AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> x4tq t rl")J4 voalo bonroogrtfbullp f (Complete in Tr iplicate) <br /> 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 <br /> made in compliance'with Sin 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 f"iis -,I.' G j : 1t, ! -7 -j; i 1,� : ; isL i'e: 4 <br /> 6767 E. F-oppiano nio'v-�,n ',a0l;J -111 -'0 It .3tkni, '1Vv ­1/2x A '84-1 <br /> Job Address city:: Lot Size PM <br /> Owner's Name <br /> Oil f8 D_87e 1-6-ph1e n Address <br /> t., -P'0-_86­X_- `7414 95207 �—­Phone'- 931 0343 <br /> Clark Well 371560 Phone 462-5597 <br /> Contracto'r's Na ..License No... <br /> ;TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 5 DESTRUCTION 11 <br /> PUMP INSTALLATION-'M -SYSTEM REPAIR 0' OTHER Ll L <br /> DISTANCE TO NEAREST:-SEPTIC.TANK 1001 SEWER LINES r iDISPOSAL FLD._L__ PROP. LINE <br /> FOUNDATION- AGRICULTURE WELL' OTHER WELL' PiTS/SUMPS <br /> INTENDED USE r TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICAT12V5 <br /> Industrial 0..Open Bottom-,. 0 Manteca -Dia. of Well Excavation Dia. of Well Casing 6 5/8" <br /> _lJ D i ornestic/P'rivate IX Gravel Pa6k 'E] Tracy Type of Casing S t e e 1 Specifications .109 <br /> I[] Public; 0 Other vL1 Delta R Depth of Grout Seal ;n Type of Grout r-a M n n <br /> 1 Surface Seal Installed by rwl ark <br /> [3 Irrigation'-' --.-Approx. Depth -�O Eastern <br /> Repair Work Done Ei Type of,pump qlih H.P. State Work Done—in c%t a 1_1 <br /> iWell Destruction 0 • Well Diameter -Sealing Material. top 501 <br /> —Depth- Filler.Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION '(No septic system permitted if public sewer is \J <br /> available within.200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> -"0/, <br /> Character of sail to a depth of 3 feev ..",—Water table depth <br /> — <br /> SEPTIC TANK S E Jype/Mfg Capacity- No. Compartments <br /> �PKG. TREATMENT PLT. Method.of Disposal <br /> Distance ioheardst:' Well F0 <br /> undation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> - FILTER'BED 'Distance to nearest:, Well Foundation Property Line <br /> isEEPA4 PITS El IDepth Size I Numbei <br /> SUMPS Distance to nearest: Well dundati6n Line <br /> DISPOSA€L PONDS' <br /> J hereby certify that i-have prepared this application and that the pork'will be done in accordance with San Joaquin county ordinances, state laws, and <br /> Irules,and regulations of the'San Joaq6i'h-Local Health District. - <br /> Home owner or licensed'agent's signature certifies the following: "I certify that iri the performance of the work for which this permit is issued, I shall not <br /> employ any parson in such manner as to:become subject to certifies the follow' " certify th ' in the pe rnworkman's compensation laws of California."Contractor's hking or sub-contracting signature <br /> . performance of the work for which this'permit is issued, I shall eploylpersons subject to workman's compensa- <br /> -tion laws'of'Calif <br /> .. iThe ip ca ca al ired inspections. Complete a drawi.ng.-on revs eve <br /> ' I. - t. - t, - , - > . . - .. V1 Veate. <br /> 1 r Delta Devt19pffi@nt <br /> s 9/24 8 <br /> in <br /> FOR DEPARTMENT USE ONLY <br /> Date <br /> D <br /> _Z_ <br /> Application Accept6d by A Area. <br /> Date /111Z <br /> n by <br /> by Date Final Inspection,Pit Or Grout Inspection I 'al Insp <br /> I Additional Cori merits. <br /> 0 Stk 466-6781 El Lodi 369-3621 El Manteca 823-7104 - E3.Tracy 835-6385 <br /> LL ,'Applicant- Return all copies to: Environmenial Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 9=1 <br /> T_ <br /> f BY DATE PERMIT'NO.' <br /> AMOUNTAEmimb <br /> INFO AMOUNT DUE CASH <br /> 6L <br /> r <br /> 7 i "KI <br /> t+EM 3-24(REV.10/83 JZ> <br />