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f 1 APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT I 9'5 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �F Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ii (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 3003 E Hammer_Lane Subdivision Name ' Owner's Name Stbckton Steel Address )'003 E Hammer Lane , Stkn Phone,931 -4 1 Contractor's Name Clark Well & EgUIPLicense No, 371560 Phone462- 6 6 i TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ E 'PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ ! DISTANCE TO NEAREST; SEPTIC TANK SEWER LI,NES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca Dia-of-Wel-l-Excavation �. YJ Domestic/Private . ❑ Gravel Pack ❑ Tracy t Dia. of Well Casing � ❑ Public Other Delta "�'❑ ❑ ! Type of.Casing ❑ Irrigation roAApppprox. E] Eastern th Specifications Cathodic Protection❑ � � Depth of Grout Seal ❑Geophysical Type of Grout ❑Other + —s f 4Surface Seal Installed by I' Repair Work Done [2 Type�bf Pump Sub H:P ---i 1 1`State Work Done e Well Destruction F-1 Well Diameter ISealing Material`(top 50') Bleeder Valve . # , Depth i Filler Material (Below 50') ! 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L: {No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: - • Water table depth SEPTIC TANK E] Type/Mfg : Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest': Well _•Foundation'. t 'f Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: , Well Foundation Property Line E SEEPAGE PITS Cj Depth Size Number } SUMPS Distance to nearest: )Well ; Foundation Property Line DISPOSAL PONDS ❑ , Y - - "` + �' �� }£ Wd� .«-�- - e ...- I�hereby certify that I have prepared this application and that the work will be done in accordance w'ithi San"Joaquin county"" T 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 is ued, I shall not employ any person in such manner as to become subject to workman', compensation laws of California." Contractor' firing or sub-contracting signator certifies the following: "I certify that in the performance bf the work for which this permit iS issued, I al employ ersons s bject to workman's compensation laws of California." t The applicant ust call 0 1 re u'r spe -ons. Complete drawing on reverse side. Date: 1 .T>>1 v 1�8 Signed X title: Sec-Tres eS l rk 3 - F .. F DEPA NT USE ONLY I I "}� Application Acc ed by Area /"` Stk 466-6781 Additional Comments: /[] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 ' Date ❑ Tracy 835-6385 Final Inspection by Applicant - Return all copies t Env ronmenta Health Permit/Services 1601 E. Hazelton Ave., P.O.ezz_�� Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO _ 10/82 500 EH 13-24 REV. 10/82 14-26