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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT � - 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED %3 (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 706 West Yettner city French 'Car Size PM Owner's Name Gordon Burkland Address Same Phone 982 551 5, Contractor Clark Well Address 2024 E Charter Wa.Y License No.371 560 Phone — TYPE OF W.LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ { PUMP INSTALLATION N' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION . r AGRICULTURE WELL OTHER WELL .PITS/SUMPS _ INTENDE� USE TYPE OF WELL ''PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial¢ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing IR Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications ':f�E,`Public ❑ Other ❑ Delta Depth of Grout SealT e of Grout IJ irrigation s ---Approx. Depth I I Eastern Surface Seal Installed by Repair-Work lbane 1 ❑ Type of Pump Sub H.P. I State Work Done_TnstR1 .1ed ,,•Well Destru tion ❑ Well Diameter Sealing Material (top 501 Depth r Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION:')1', REPAIR/ADDITION i 1 DESTRUCTION [ I (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK f]TypelMfg Capacity L - � * No. Compartments PKG. TREATMENT PLT. OMethod of D - isposal i Distance to nearest: Well , Foundation Property Line t LEACHING LINE Cl No. & Length of lines is Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size i Number SUMPS L1 Distance to nearest: Well t Foundation Property Line d m 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, anp rules and re' ulations of the San Joaquin Local Health Dis 'ct. Home own ' r licensed agent's signature cert'res the Poll Ing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any•pe son in su h mann as to bec subject orkmad's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol wing: 'I c ify in th o ance of,h work for which this permit is issued, I shall employ persons subject toyworkman's compensa- tion lawsof4 I'orni r � 1 The appl- t a ��Ur s t' n o drawi' on reverse sidd +r_j• }{ s i Signed X Title:S — See—Tres Date: 5�5/89 t FOR DEPARTMENT USE ONLY ApplicationAccepted by - Date r�— � Area Pit or Grou Inspection by Date Final Inspection bye a Additional Comments: ❑ Stk 461,-67$1 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 Applicant-,Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / i t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r.EH 13-21(REV.r i kL) O� EH 11-20 ' - f 1 a