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k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _ PERMIT EXPIRES 1 YEAR FROM DATE ISSr.UED I+ i (Complete in Triplicate) ition is r, n described.THs Application is hereby made to he Joa quin County Ordinance nalnce No.District Health 549 for sewage or INo. 1862 for well/pump and the Rules and t to construct and/or install the work (Regulatci ions of the San Joaquin Made in compliance with San Joaquin + Local Health District. ," STOCKTON Lot size PM Job Address 633 .. WATERLOO ROAD city Ilr 6331 WATERLOO ROAD Phone 931 3.22.7 CARL DE MENT Address owners Name __ . . y 1.1.62.-7676 37�,56fl Phone Contractor's Name _ CLARK", WELL License No. qq WELL ❑ WL REPLACEMENT El DESTRUCTION 13l TYPE OF WELL/PUMP: NEW WELLSYSTEM REPAIR 13 OTHER 11t �I PUMP INSTALLATION ? DISPOSAL FLD. " PROP. LINE SEWER LINES —— PITS/SUMPS i�D1STANGE TO NEAREST: SEPTIC TANK x AGRICULTURE WELL OTHER WELL FOUNDATION �� INTENDED USE TYP' ;' E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Dia:.of Well Excavation + E C1 Industrial ❑ Open Bottom ❑ Manteca 1 Specifications El Domestic/Private El Gravel Pack ❑ Tracy Type of-.Casing ` ❑ Delta .Depth of Grout Seal Type of Grout � L3 Public F] Other � 5urface�•Seal Installed by --Approx. Depth ❑ Eastern l ns a a 10ri u ❑ Irrigation Sub 2HP State Work Done i+ Repair Work Done ❑ Type of Pump H.P. Etr Sealing Material (top 50"1 Well destruction L] Well Diameter Filler Material (Below 60') Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR!ADDITION ❑ DESTRUCTION ❑ availableseptic withine200 feet.) if public sewer is Installation will serve: Residence— Commercial_ Other t Number of livingunits:-— --=Number of"bedrooms "`"`"`�'"`�� _ Water table depth 1 Character of soil to a depth of 3 feet: Capacity No. Compartments! U SEPTIC TANK ❑ Type/Mfg Method of Disposal' I PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line ap f Total lengthtsize -LEACHING LINE ❑ 'No. & Length of lines Property Line FILTER BED E3 Distance to nearest: Well Foundation 4 i Size - Number SEEPAGE PITS ❑ Oepth _ property Line SUMPS ❑ i'Distance to nearest: Well Foundation I DISPOSAL PONDS Ely certify that I have prepared this application and that the work wi11 be done in accordance with San Joaquin county ordinances, state laws, and I hereb rules and regulations of the San Joaquin Local Health District.' k.foT I Home owner licensed agent's signature certifies the following:"l certify that in the performance of the Contractor's o tract which this permit is issued, I signature shall not i employ any on in such manner as to bec me subject to workman's compensation laws of California." Contra eos snslring or sub subject to wprkman'scompensa certifies the II wing:"l c ify that in the armance f the work-for which this permit is issued, I shall employ p 1 k tion laws of at ornia." The applica call a ired io s. G plete drawing on reverse side. 26 Feb 88 k Title: Sec-Tres Date: 4e Signed FOR iflEPARTMENT USE ONLY N� Date Area _. Application Accepted by / " Final Inspection by��G''�._ Dee Pit or Grout Inspection by Date��- IIr Additional Comments: ❑ Stk 466 6781 ❑ L i 369-3621 Manteca 7104 El Tracy 835-6385 i Applicant Return all copies to: Environmen at Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK# RECEIVED BY DATE PERMITNO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO 3 r EK 13-21 IREV.101831 d0 �I EH 1428