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�3- �3 APPLICATION FOR PERMIT Z SAN jOAQUi!! LOCAL HEALTH DISTRICT PERMIT NO. 1601 ET. elephoneN(209) 466-6780 , CA 1NDATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ll ll (Complete in Triplicate) oce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ""ation is hereby made to the 5an'Joaquil'avcal Health District fora permit to construct and/or instal} 'the work herein Appl7c described. This application is made in romp and the Rules and Regulations of the San Joaquin Local Heal Subdivision Name Phone 931—1002 6776 E. Fd ianO job Address Phone 462-5597 owner's Name 3Cllarl Farms-Paul 5010 Ls License'No. 073 1560��dreth f Contractor's Name Clark WELL REPLACEMENT 36DESTRUCTION ORK: ❑ s WNEW WELL �... OTHER TYPE OF WELL/PUMP U . PUMP INSTALLATION ❑ SYSTEM REPAIR U DISPOSAL FCD. PRO?. LINE +5n' I t t DISTANCE TO NEAREST: SEPTIC TANK -C- 5 SEWER LINES Q_�— OTHER WELL 2 5 t PITS/SUMPS FOUNDATION AGRICULTURE WELL `1 w PROBLEM AREA CONSTRUCTION SPECIFICATIONS 10 5/811 INTENDED USE TYPE DF WELL $ Industrial U Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private �] Gravel Pack ❑Tracy '� 3�e2� ❑ Other E]Delta Type of Casing ❑ Public Approx. E]Eastern Specifications . 9 Sack mix 501 i V Irrigation Depth 1 Depth of Grout Seal g sack X ❑Cathodic Protection Type of Grout ❑ physical C lar k Geo � Surface Seal Installed by ❑Other State Work Done ff10Ve UCC! + 11 Repair Work Done Type of Pump S� u b H'P' ? ---�. Well Diameter �� Sealing Material (tap 5D') � Well Destruction �❑ Filler Materia} (Below 50') f Depth epage pit permitted if public sewer is ' REPAIR/ADDITION ❑ (No septic tank or seavailable within 200 feet.) k TYPE OF SEPTIC WORK: NEW INSTALLATION L� 1 Commercial _ Other Installation will serve: Residence , Lot size �- k Number of living units: Number of bedrooms — Water table depth Character of soil to a depth of 3 feet:f Capacity 1— No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal Capacity � PKG. TREATMENT PLT. ❑ Type/Mfg Property Line SEWAGE SYSTEM � Distance to nearest: Well — Foundation _�"� DESTRUCTION Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation Size Number SEEPAGE FITS [� Depth 1.__ Property.Line SUMPS �.� L` Distance to nearest: Well Foundation __�_— OISPOSAL PONDS ❑ ` certify that I have prepared this applicationheand Santhat Joaquenwork Localwill Heabthdone Districtccordaance ofwith theSan woJoaquin rk for which this C I hereby Y that in the perform ordinances, state laws, and rules and regulations o f Rome owner or licensed agent's signature certifies the following: I certify permit is issued, 1 shall ploy any person in such manner as to become subject to workmanIs compensation laws of California. signature certifies the following: „ certifytion laws thaof taintheiyerformance of the work for which j Contractor's hiring or s ont m o gpers s subject to workman's comp this permit is issue , Lica st 1 fo l q s ections. Complete drawing on reverse si ey Date: The app Title: Signed X E ARTME SE ONLYt �tk 466-67$1 Area Application Accepted ❑ Lodi 369-3621 Additional COMM-nts: Date 9 ❑ Manteca 823-7104 Pit or Grout Inspection bypate 4 95201 [3 Tracy 835,-63B5 - ” t Final Inspection by Applicant - Return all copies to; Environmental Health Permit/Services 160 E. aze}ton Ave., P.O. Box 2009, Stk., � AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. FEEE, H4 q 7 INFOQ (�(�3--1500" EH 13-24 REV. 10/82 14-26