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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA P Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to the San Joaquin Local HealthDistrict for a permit to construct and/or install the work herein described. This application is f made in compliance with'San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rul'I s and Regulations of the Sart Joaquin Local Health District. ` 1'26.44, S: Harlan-Rd! `�_ Lathrop Lot DP Record -r Job Address City Lot Size PM Middle K Farina 12644 Harland ij 962-5575 Owner's Name Address Phone Clark Well NAXX 371560 Phone TYPE 462-7676 Contractor's Name License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IN DESTRUC1jION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK n SEWER LINES na DISPOSAL FLD.na PROP. LINE +30 FOUNDATION AGRICULTURE WELL OTHER WELL 1 f PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI TI tt 6 / tt ❑ Industrial 171 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing "Domestic/Private )i( Gravel Pack F-1 Tracy Type of Casing_ }oal Iw Specifications #12 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 5 n f* Type of Gro ❑ Irrigation --Approx..Depth ❑ Eastern Surface Seal Installed by C.1 ark Repair Work Done ❑ Type'of Pump _arth H.P. I State Work Done ne+a1 1 WeI D struction dC; Well Diameter ._ Sealing Material itop 50'i 11� Depth x317— Filler Material {Below 501 V TYPE F SEPTIC YR KK: N W INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION C1 (No septic system permitted if public sewer.is 'Z �C J] ?4r, r - available witAin 200 feet.) °ffttstallation will serve: /fieside ce_ Commercial_ Other ! l Number of living units: Number of bedrooms ! f Character of soil to a depth of 3 feet: —Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments C/6 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 a SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I! 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 licen r agent's si ure certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in ch or as t ecome subject to orkman's compensation laws of California."Contractor s hiring or sub-contracting signature certifies the following:' rtify hat in t ante of t work for which this permit is issued, I shall employ persons subject to workman's compensa- , tion laws of C ifo ia. The apptica cal fo II a 'in I to dr ing on reverse side. i Signed Title: VP—Clark ! Date: Sept 1985 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 13 Pit or Grout Inspac ion by Date Final Inspection by Date 0 Additional Comme s: r �� C Gip y/l 1!h !'j?Orn r _ ❑ 5tk 466-6781 ❑ Lodi 369 3621 Manteca 823 7104 ❑ racy 835 6385 Applicant- Return all co res to, Environmental a Ith Permit/Services 1601 E. Hazelton Ave., P.O. ox 2009, Stk., cA 01 S Oc�C- ,yl r o 3 m DO-Ileo !f 1aC u',v�- -f-� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. 44' INFO CASH �j� „ Q +EH 1324 MEV.101831 X� Ct—lb 10q& EH 1428 V If