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APPLICATION FOR PERMIT Q� SAN JOAQUiN LOCAL HEALTH DISTRICT � , 3-9-7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 DATE ISSUED 5117 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. Jab Address 2 62 Mariposa Subdivision Name Owner's Name Liberty Fixtures — Address2467 Marisposa Phone 948-11'76 Contractor's Name Clark Well License No. 60 Phone 462- 559- TYPE OF WELL/PUMP WORK: NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION W cA PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK }5 0 t SEWER LINES DISPOSAL FED, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation ,1 U Domestic/Private Gravel Pack Tracy Dia. of Well Casing 6 '- I—] Public L Other [] Delta Type of Casing # 1 0Q ❑ Irrigation Approx. [:] Eastern --�� Depth Specifications ❑ Cathodic Protection Depth of Grout Seal 5 n Geophysical Type of Grout 4 S _Ck IClI X �A3'1f3Rc('.PII1E11t) U Other Surface Seal Installed by C l a rk Repair Work Done ❑ Type of Pump Sub H.P. _1 State Work Done TnS`t:a.11 Well Destruction Lj Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is �- available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS IJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI I hereby certify that I have pre a is application and that the work will be done in accordance with San Joaquin county ordinances, state laws, es and reg ations of the San Joaquin Local Health District. Home owner or livens agent's signature ertifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ an person in such manner as to become subject to workman& compensation laws of California." Contractor's hiring ub-c t ctin signature ertifies the fallowing: "I certify that in the performance of the work for which this permit is .ss d, 1 ons s ject to workman's compensation laws of California." The applica s cal al ui d ' s ons. Complete drawing on reverse side. Signed X Title: VP-Clark Well Date: 18Nia v 19&-3 FOR D PART T USE ONLY Application Accepted by Area Erltk 466-6781 Additional Comments: [:] Lodi 369-3621 Pit or Grout Inspection by —7 Date -4 ff-3 A� L-1 Manteca 823-7104 ` Trac 835-6385 Final Inspection by Date -/ ❑ Y Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 11 '33 83 EH 13-24 REV. 10/82 10/82 500 14-26 r