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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> LPERM <br /> IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> A <br /> p application is <br /> Application is he+eby made to the San Joaquin Local Health district for permit to construct and/or instal!the work herein described. This <br /> 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 <br /> Local Health District. .I I,Ot O Record <br /> J Stockton Pre-72 PM 22 acres <br /> 5227 East 'Morada Inane City Lot Sae <br /> Job Address ,.' <br /> Bailey & Bennett Address <br /> Same Phone g3�'-'2603 <br /> Owner's Name - r 6 <br /> Clark Well _ Address 2024 East Charter License ES UC ON o Phone <br /> X62-76? <br /> ONS <br /> Contractor DESTRUCTION ❑ <br /> WELL REPLACEMENT ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR ❑ OTHER JO 7Grout�-. <br /> l '. <br /> PUMP INSTALLATIONXf t <br /> � SEWER LINES �--- DISPOSAL FLS. PROLINE _DISTANCE TO NEAREST: SEPTIC TANK ` — f PITSFOUNDATION AGRICULTURE WELLOTHER WELL. C—INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFTlrr Dia, o6 5/8 r❑ Industrial d Open Bottom ❑ Manteca Dia. of We11 Excavation 12r T e of Casing SteelSpecifDomestic/Private �1 Gravel.Pack ❑-Tracy yP g ypackDepth of Grout Seal 50 T e <br /> ['1 Public ❑ Other C1 Delta Clark <br /> t Surface Seal Installed by } <br /> 'Repair <br /> irrigation __Approx. Depth I'1 Eastern g J 1nStall ^.J <br /> E , i Sub H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material )top 501 <br /> f Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK'.' NEW INSTALLATION ['I REPAIR/ADDITION LI DESTRUCTION E I availablerwithin 200 feets em .) <br /> if public sewer is . <br /> Installation will serve: Residence;� Commercial Other _ <br /> Number of living units: Number bf bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑.."Type/Mfg Capacity <br /> Method of Disposal <br /> t PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> i <br /> Total length/size <br /> t LEACHING LINE 0 No. & Length of lines Property Line <br /> !, FILTER BED ❑ Distance to nearest: Well Foundation <br /> t� <br /> t1 Size Number <br /> SEEPAGE PITS l 1 Depth Property Line <br /> SUMPS L-1Distanceto nearest: Well Foundation <br /> 1 <br /> DISPOSAL PONDS ❑ <br /> I I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> f rules and regulations of the San Joaquin Local Health District. <br /> 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, l signature <br /> shall not <br /> employ any person in such manner A to become subject to workman's compansap n laws of California." Contractor's nsi$subject tog or bwo�kman'fscompensa <br /> certifies the following:"'I ertify t pe rmance of the w k for which this permit is issued, I shall employ p 1 <br /> 4 tion laws of Cali ornia; <br /> {4 The applican for all ire ins tion rawing on reverse side. <br /> F Title: VP--Clark Well Date: 27 Aug9�7 <br /> i Signed X <br /> A 4 FOR DEPARTMENT USE ONLY <br /> Date b f— Area <br /> Application Accepted by <br /> Final Inspection by ' <br /> Date <br /> Pit or Grout Inspection by Dat <br /> Additional Comments: <br /> © 7 <br /> 466-6781 D Lodi 369-3621 D Manteca 823-7104 zIS* 835 6385 , <br /> plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> elt <br /> l FEE CK RECEIVED BY DATE PERMIT'NO. rr <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> ' s EH 13-24(REV.I/e 5) <br /> k EH 14-26 <br />