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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL` Tl ON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) tion is hereby made to th San Joaquin Local Health District for a permit to construct and/or instali the work herein described.This application is L ,549 for sewage or No. 1862 for w,111purep and the Rules and Regulations of the Son i,adl6in ads in compliance with San Joltuin County Ordinance No Local Health District.. I 2771 E I French Cam2 Rd. City Manteca LotSize +40 aCreSPM— J Job Address — owner's Name Ace 70mito Address Phone 'lark Wel Address 2024 E. Char er License No. 3 7 15 0 Phone Contractor C DESTRUCTION D � 1, N WELL REPLALtryltrii I X-X OTHER 0 TYPE OF WELUPUMP� EW WELL 0 PUMP INSIALLATIOkkk SYSTEM REPAIR Ll 0 NEAREST: SEltTtC TANK SEWER LINES — DISPOSAL FLD.— PROP. LINE DISTANCE T FOINDATION AGRICULTURE WELL. OTHER WE I PITS/SUMPS '9 INTENDED USE TYPE L PROBLEM AREA CONSTRUCTION SPECIFICATIONS �ir WEL Dia. of Well Excavation It Dial. of Well Casing 1611 111 Open a.M., X(R*Aanteca XXLkk,d.st,ial 4 Specifications .250 * Domestic Private xRxq,avel Pack 0 Tracy Type of Casing__staa_i-- Type of Great-eeMeTrt--,GrC Lit * Public F1 �thiil - n Delta Depth of Gr"t Seal 440-L— I I Irrigation . I-Approx. Depth I I Eastern Surface Seal Installed by Glark Repair Work Done El T 'k of Pump Turbin H-P. State Work Done Well Destruction 0 Well Diameter sealing Material (top 50', De h� Filler Material (Below 501 tied if public sewer -s TYPE OF SEPTIC WORK: N W INSTALLATION I I RD� :.iil: IDD.110.141 1 CES!RUCTtON I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resii lance— Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK 0 Type/Mfg Capacity— No. Compartments PKG.TREATMENT PLT.0 1 1 Method of Disposal Distance to nearest: well Foundation— Property Line Total length/size— LEACHING LINE Li I No. & Length of lines FILTER BED 0 Distance to nearest: Well Foundation � Property Line Size--- Number SEEPAGE PITS I I !)epth —Well Foundation— Property Line SUMPS 0 Distance to nearest: DISPOSAL PONDS 0 rate laws, and I hereby canify that I hhava pared this application and,that the work will be done in accordance with San Joaquin county ordinances, 5 rules and regulations of the n Joaquin Local Health Diberict. a sign I Home owner or licensed age ' ature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pawn in such nner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-coriftacting signature ceffifies the following:"I can ihatinthe rformance of the work for which this permit is issued, I shall employ persons subject ioworkman's vompensa- tion Laws C -forma."y I I lead S tions. Complete drawing on reverse side. The applies us c Signed X-- Title: VP Clark Well Date: 5 Ap- go DEPARTMENT USE ONLY Date At" IS Application Accepted by -I;-- Date 10 Pit or Grout Inspection by 4��. Date /0- 49FInall Inspection p,?e t Additional Comments: 0 Stk 466-6781 369-3621 0 Manteca 823-7104 C3 Tracy 635-6385 Box 2D09, Stk., CA 9SM1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. FEE AMOUNT I i fill� I I I ECEIVED By I A jr�E FERMIT'NO. A Sit INFO L4-IS-CA g na EK 1�24(AV 1 EH 1�215