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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 5345 Oakview LaneStocktonCity Lot Size PM <br /> Owner's Name Mark French Address 5345 Oakview Lane Phone 946-22Q6 <br /> Contractor Clark Well Address 2024 E Charter Way License No. 371560 Phone 46207676 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ix SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> I` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing GI <br /> OCDomestic/Private ❑ Gravel Pack ❑ Trac T r W <br /> Tracy Type of Casing ` Specifications --6. , <br /> F7 Public Type of Grout—4 Other F1 Delta Depth of Grout Seal T { <br /> I Irrigation _.App x. Depth 1 1 Eastern Surface Seal Installed by V1 <br /> Repair Work`bone�❑ Type of. Pump Sub H.P. • State Work Done _ Installed 7 <br /> Well Destruction:t 0 WeII,biameter Sealing Material (top 50') � y <br /> _ s _ <br /> Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1.1 DESTRUCTION I 1 INo septic system permitted if public ewer is <br /> j.� available within 200 feet.) <br /> Installation will se <br /> — <br /> rve: Residence Commercial Other <br /> 1_ <br /> Number of living units: ' N-umber of bedrooms.f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity f No. Compartments <br /> PKG. TREATMENT PLT. ❑ 9 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i� <br /> LEACHING LINE ❑ No. & Length of lines Total'length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: WellFoundation f — Property Line <br /> DISPOSAL PONDS ❑ t`� <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 r <br /> rules and regulations of the San Joaquin Local Health District. I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any rson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the owing: "I certify that&tha a of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of lifornia." f <br /> The applicant ust ca for a quits. mpleta drawing on reverse side. <br /> Signed Title: SeC~Tres I Date: 24 May 1.988 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grcut traction by Date._. _- __Final_Ins ection.b "�1 _ `rte; <br /> p y- , - •. Date.7�-Z �Y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE 1 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24(REV,i i n 51 - <br /> EH t4-28 <br />