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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 L. HAZELTON AVE., STOCKTON, CA PERMIT NO. �J Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM GATE ISSUED GATE ISSUED ,7-TV rZ�pp��jr,/ ��} (Complete in Triplicate) CC 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 Corner—Thorton&Wagner Heig�tb$ivision Name o'Spp9- Z7fJ — b,6 Owner's Name Dados Engineerind Address 302 8 Woodbridgey CA 95254ne 368-9314 { Contractor's Nam,Clark Well & Equi 3 License No. 371 560 Phone 462-5597 TYPE OF WELL/PUMP WORK. NEW WELL ❑ WELL REPLACEMENT DESTRUCTION p� PUMP INSTALLATION ❑ SYSTEM REPAIRU OTHER U W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private FGravel Pack Tracy Dia. of Well Casing r Public Other Delta irrigation Type of Casing V 9 Approx. Eastern Specifications [—] Cathodic Protection Depth n Geophysical Depth of Grout Seal Cb Type of Grout Other ' Surface Seal Installed by '. Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction well Diameter 4't Sealing Material (top 501) 5 Sack mix Sand &_(cami3at) Depth 1701 Filler Material (Below 50') same TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 240 feet.) j Installation will serve: Residence Commercial Other j Number of living units: Number of bedrooms Lot size fi Character of soil to a depth of 3 feet: t Water table depth 4 SEPTIC TANK [-] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, U Type/Mfg Capacity Method of Disposal .� SEWAGE SYSTEM Ei Distance to nearest: well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line 7 5 T 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, and rules and regulations of the San Joaquin Local Health District. 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 t em y any person in such manner as to become subject to workmans compensation laws of California." Contractor's hiring or so c nt ac i nature certifies the following: "I certify that in the performance of the work for which this permit is ssu , I 1 em y e son ubject to workman's compensation laws of California." The applican 11 fo 1 qu . ttions. Complete drawing on reverse side. Signed X Title: _ Date: 7 July 1983 OR D ARTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: % Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by 4. Date L7 Tracy 835-5385 Applicant - Return all copies to: ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 I0182 500 14-26