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r APPLICATION FOR PERMITS SAN JOAQUIN 'LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA F Telephone (209) 466-6781 'r - 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. , 1624 Hwy 99 Frontage Rd Manteca Job Address City Lot Size PM Southland Mobile Home Park same ©2 S7 Owner's Name I Address Phone 823_ f Clark Well 2024 E. Charter Why 371560 46?-X7676-`—` Contractor Address Li ense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \ t PUMP INSTALLATION CX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surfa a Seal Installed by Repair Work Done El Type of Pump 3 u b H.P. 7 172 State Work Done n S a Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 �. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public'sewer is available within 200 feet./ Installation wi e: Residence_I Commercial— Other Number of living units: Number of bedrooms M Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg { Capacity No. Compartments 11 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well undation Property Line a LEACHING LINE ❑ No. & Leng'h of lines nNumber ngth/size FILTER BED ❑ Distance to nearest: Well Foundationrty Line SEEPAGE PITS ❑ Depth I Size SUMPS ❑ Distance to nearest: Well FoundationProperty Line DISPOSAL PONDS ❑ .i 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la�s;.and rules and regulations of the San Joaquin t:ocal 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 anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature . certifies the followin I certify at in a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C lifor t The applica t fo al eq s1 tions. Complete drawing on reverse side. Signed Title: VP—Clark Well Date:20 JUlY 1987 FOR DEPART ENT USE ONLY Application Accepted by Date Area k Pit or Grout Inspection by Date Final Inspection by� - Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE E{ CK i INFO AMOUNT DUE 61 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13-24fREV.7/esl6&4 Q] �21 EH 1428 v -