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�. 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 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Pre-72 Job Address 11123 Live Oak Fid Stkn City Lot Size PM Owner's Name ManueI Valadao Address 937 S. Commerce Phone 462-2286 ContractorClark Well Address 2t]24 _Eas-t Chartdr Wali -� "-3715-6.0 46-2-7676 Ly cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ® DESTRUCTION I( PUMP INSTALLAT(81,12 SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK X11 SEWER LINES DISPOSAL FLD. PROP. LINE ✓ -FOUNDATION. AGRICULTURE WELL OTHER WELL+75 f PITS/SUMPS iNTENDED USE ; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA 0 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationf�l 6 5/8R PVC Dia. of Well Cay�igg ](Domestic/Private XX Gravel Pack ❑ Tracy Type of Casing Specifications L 1160 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 9 sack ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ar Repair Work Done, sub❑ Type of Pump H.P. 1 State Work Qone install in tie Well Destruction ❑ Well Diameter Sealing Material (top 50'1 OO —11P Dy owner ! Depth .Filler Material (Below 501) , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg ? CapacityNo. Campanments__ PKG. TREATMENT PLT. ❑ --f 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 SEEPAGE PITS ❑ Depth - Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 not employ any person in such manner as to become subject to workman's compensation laws of Cal'rfomia."Contractor's hiring or sub-contracting signature certifies the following:"I certify rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica call r I uire in ct194 om to awing on reverse side. Signed title: VP-Clark Well. Date: 25 June 1967 EPARTMENT.USE ONLY Application Accepted by Y— - - - Date Area Pit or®rout nspection by p to Final Inspe tion by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi—369-3521 ❑ Manteca 823-7104—M Tracy"-835_Mffi�_ /a4,iei� � �I Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 " FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. ` INFO CASH EH 13-24 ry24 '; + EH 14281REV.v/&51 ..{ O'a U � 2��% 1.