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APPLICATION FOR PERMIT -7 SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DA 1%her � 3 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��wvv (Complete it Triplicate) < Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the 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 24 6? IVIarilposa Subdivision Name Owner's Name Liberty Fixtures Address 46 Marls OS Phone 948.-.1176— - Contractor's Name Clark We11 License No. -U-1-560 Phone A n TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION �J Od cki PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ W W DISTANCE TO NEAREST: SEPTIC TANK H _5 0 1 SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �},� W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial [J Open Bottom ❑ Manteca Dia. of Well Excavation 1 0 /�" I Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing 6 " ❑ Public ❑OtherDelta ❑ Type of Casing ❑ Irrigation Approx. ❑Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal Cllr ❑Geophysical Type of Grout mrnt) ❑Other Surface Seal Installed by Repair Work Done G Type of Pump Sub H.P. State Work Done Ins LaJ-1- Well Destruction [-j Well Diameter Sealing Material (top 50') L Depth Filler Material (Below 501 No septic tank or seepage pit permitted if public sewer is �r TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR/ADDITION Lj ( p available within 200 feet.) I Installation will serve: Residence — Commercial Other - Number of living units: Number bedrooms Lot size I[ of Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION Total length/size LEACHING LINE LJ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number � SUMPS L_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑I 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 licen agent's signature ertifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ an person in such manner as to become subject to workman compensation laws of Californiac of the work for which Contractor's hiring ub-c ctin signature ertifies the following: "I certify that in the performance h this permit is 'ss d 1 ons s ject to workman's compensation laws of California." , The applica s cal al ui d ' sp ons. Complete drawing on reverse side. Date: Signed X Title: VP-C larkwell 1 w 3 FOR D PART T USE ONLY /1 211-s-tk 466-5781 Application Accepted by Area Gd Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grp t Inspection by Date -�"g3 At [7] Tracy 835-6385 Final Inspection by _ Date �p-/� ��_ ❑ Applicant - Return all copies to: �,4nmental Health Permit/Services 16CI E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y gDATEq 2 INFO 0,C) S D O 3 10/82 500 EH 13-24 REV. 10/82 ._ 14-26