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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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, Job Address 10393 East Waterloo Road City Stockton Lot Size PM Owner's Name Thomas L. Pack Address 10393 E Waterloo Road Phone 931-5695 Contractor Clark Well Address 2024 E Charter Way- License No. 371.560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 12 SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrials ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - r 9 Domestic Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications FI Public i C Other Cl Delta Depth of Grout Seal Type of Grout 1 1 Irrigation}. --Approx. Depth l I Eastern Surface Seal installed by _ Repair WorktDone E) Type of Pump Sub H.P. THP State Work Done' Installed 1' 0 Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 v Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is U� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t Number of living units: Number of bedrooms Character"of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method oftisposal Distance to nearest: Well Foundation Property Line a r Y LEACHING ;INE ❑ No. & Length of lines Total length/size E FILTER BED r ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS "t Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS' ❑ I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Horne owner or licensed agent's signature certifies the followi6§:-J certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject tojwoekman's-compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f wing: "I certify that in the pert mance of the work for whiah'this'permit is issued, I shall employ persons subject to workman's compensa- tion laws of aifornia." — 9 �� R.)sem The applican u t call or req rl i s c ns. Complete drawing on raverse`side.�` Signed X Title: _-Sec aTre,s _•- Date: 31. Mar 88 FOR DEPARTMENT USE UdY y Application Accepted by Date / r.ft � Area 6� Pit or Grout Inspection by Date Final Inspection by Date a a 4 ._ Additional Comments_:_ ❑ Stk 466-6781 ❑_Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 vf€ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �4 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.tiws7 } �.0 X \/9S EH 14-28 ,