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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tip. c+c _f (Complete in Triplicate) i 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. Pre-1972 10111. "N `Hwy 99 Stkn Job Address -. City Lot size PM Ireland Landscaping dame 462-7371 Owner's Name Address Phone Contractor Clark Well Address 2024 East Charter License No.371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK h fit SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 5 t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI TI tt 5ra tl ^v Ll Industrial ID Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Ca�j�tg X1 Domestic/Private Gravel Pack ❑ Tracy Type of Casing P V C SpecificationsbU bul 1,Lg sack eCk ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El Irrigation �-_4pprox. Depth ❑ Eastern Surface Seal Installed by OF Repair Work Done C3 Type of Pump 5u.b H.P. 3 State Work Done instali Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence�� Commercial_ Other Number of living units: Nu' 6 r of bedrooms' Character of soil to a depth of 3 feet: Water table depth / SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments f PKG. TREATMENT PLT. ❑ } ii + .. Method of Disposal r • ,: �, -'Distance to nearest: Wel! Foundation Property Line LEACHING LINE y 0;!.No. & Length of lines Total length/size 1 FILTER BED f-Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size_ Number SUMPS ❑ Distance to nearest: "' Well Foundation Property Line ° DISPOSAL PONDS ❑ t ^, I hereby certify that I have prepared this application and'#hat 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 California."Contractor`s hiring or sub-contracting signature certifies the following: "I certify i rf mance of the wank for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of C 'or ' The appli m call r all r q 'r i cti drawing on reverse side. 3 Aug987 p VP—Clark 9 Signed Title: Date: M FOR DEPARTMENT USE ONLY s Application Accepted by \6ATN Date<> ,�"� ! Area d Pit Q-tout InypeNct�io�n by Daye� 1 l in I I cptgio'n b Date f�wJ a Additional Comments: �lrr2- z ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E FEE AMOUNT DUE'`� AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13.241REV.1/85) �'15 r EH 14-28 i