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APPLICATION FOR PERMIT �SANIJOAQUIN LOCAL HEALTH DISTRICT ' t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. Job Address 1010 Zeph r Street city Stkn Lot sizel 5 acres� PM 4 Owner's Name Air ProducT'S Address SAMp Phgne W F ! Contractor Clark _ Address2Q2'4 ' Chdrf7er. . License No: 1 6r1 Phone4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P_UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Lk Test Well DISTANCE TO NEAREST: SEPTIC TANK None SEWER LINES Nc)np- _ DISPOSAL FLO. None PROP. LINE,�QD t FOUNDATION 75 t AGRICULTURE WELL NDMe— OTHER WELL PITS/SUMPS ASE' 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 n Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout I ) Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 f Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I 1 DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Q Installation will serve: Residence_ Commercial_ Other Number of living units: T_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well FoundationProperty Line , LEACHING LINE ❑ No. & Length of lines iyr r-== Total length/siie s, FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line r }5EEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that 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 that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- tion laws of California." The applicant c r r it pact! ns. omplete drawing on reverse side. VP Clark Well 12 Aprill.89 I Signed Title: Date: FO DEPARTMENT USE ONLY Application Accepted by Date__ / _/ Area [ $ V Pit or Grout Inspection by Data 0 Z d p Final Inspection by Date Additional Comments: —/Q_[A�Q l d�x-C.i_ j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104f ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I t1c�+T rrt�t sou r` f 7` Y Ii INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY. DATE PERMIT-NO- { a EH 14-241REV.tin51 _ !--{�� -77 - EH 11-2$