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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 tfle San Joaquin Local Health District. ! Job Address End of Louise& SJ._�.iVer •_. ' _ City_ T,athrr,� Lot Size - PM Owners Name Ford ConstruCtion Address 639 EPhone 3 3:3 1116 Contractor Clark Well I_ ; Addressrha-ri-er- License No. �'�� ^,—Phone TYPE OF WELL/PUMP: NEW WELL F] WELL REPLACEMENT ❑ DESTRUCTIOWO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ R 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 ❑ Industrial EJ Open Bottom El Manteca Dia. of Well Excavation LJ Domestic/ of Well Casing j Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public 71 Other fl Delta Depth of Grout Seal i I IrrigationType of Grout -Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done_ Well Destruction ❑ Well Diameter rr i � �-.._ Sealing Material (top 50'1 Depth r Filler Material (Below 50') , TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewerJis , 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: r- Water table depth SEPTIC TANK ❑ Type/Mfg+ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ' ❑ No. 8 Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well_ _ Foundation � Property Line � r� SEEPAGE PITS i I Depth r Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 - 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 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 ins nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the following: 'I Corti Iha in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C Ii f The applic u f all a uir inspections.pections. Complete drawing on reverse side. t L Signed . Title: VP Clark Well Date: 7 2Apri 190 f — F .PARTMENT USE ONLY C Application Accepted by Date [ Area Pit or Grout Inspection by Date Final Inspection b �3 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FE AMOUNT DUE AMOUNT REMITTEDCK INF CASH RECEIVED BYaDATE PERM ND. 4 + EH 13-21[REV.1i951 2 4�EH 14-29 , >°a 9U�?