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i • APPLICATION FOR'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES tYEAR FROM DATE .ISSUED (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. I 3400 ' East of McIntire Ra. (parcel. # 023-130-14) Job Address 2030 ' North of HWV 12 City Clements Lot Size PM ` Owner's Name Brain & Beth Colburn Address 413 W. Stewart Rd Lath r0ppneCa (209)982--9629 Contractor Purvi an ce DrilL_eKs,,dd�ae. P. O. Box 64 Li.n e-Tkense No.-3-7-7-9-23—Phone TYPE OF WELL/PUMP: , NEW WELL XK WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.❑ _, SYSTEM REPAIR, ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLO. PROP. LINE a} I FOUNDATION ' t AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial t�C1 Open Bottom ❑ Manteca Dia. of Well Excavation e 12 Dia. of Well Casing 1 w Xi-Domestic/Privaie' OGravel Pack ❑ Tracy Type of Casing._ stPA] Specifications .1$$ f-1 Public Cl Other n Delta Depth of Grout Seal _ �} r Type of Grout X Irrigation # Approxi Depth I I Eastern Surface Seal Installed by Ceptt Repair Work Done " ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 [1+i Depth ! r`1 p Filler Material 113elow 50). TYPE OF SEPTIC.WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION ( t DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve:-Residence�� - Commercial i Other z I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r i Water table depth SEPTIC TANK b ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line * �' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 ' SEEPAGE PITS l I Depth Size Number r SUMPS t ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r +.•''"" 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 rules and regulations of the San Joaquin Local Health District. , . t k Home owner or licensed agent's signature certifies the following: "I certify that in the peef'6rn ance of the work for which this permit is issued, I shall not employ any person�in such manner as to"become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c I far ed inspections. Complete drawing on reverse side. r V. Signed / Title: President Date: 8/18/88- FOR 18FOR DEPARTMENT USE ONLY ! ' m_ Application Accepted by Date '3 Area—_ d r b Pit or Grout Inspection by ^""Date�T�`�� b Inspection Final Ins b' f �` , �cp V I t - P Y .Date, Additional Comments: i ❑ Stk 466-6781 LJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .Applicant- Return alt copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE R AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. + EH 13.21/REV.I/K 51 00 Z2 EH 11-241 �[C�! 89