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"")1X, cg� 3- l` 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 93- 341_ Telephone (209) 466-6781 DATE ISSUED 'T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i. (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. Job Address_ 11 243 N. Ham Lane __ Subdivision Name Owner's Name 12G&E, Address] Florin--Perkins Rd Sac Phone Contractor's Name Clark ell License No. 371560 Phone 2- Z F u TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE S .? FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation 1 2_"__ i ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing Public Other Delta Type of Casing [ Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal 17 Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter 1 211 _ Sealing Material (top 50') _ sack mix Depth Filler Material (Below 50') sand � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 1J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal , F Distance to nearest: Well Foundation Property Line / } E LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 ) E SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line 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 shal of emp y any person in such manner as to become subject to workman!s compensation laws of California." Contractor's hiring o AuLb- tra, Ing ignatu certifies the following: "I certify that in the performance of the work for which this permit is iss e em p rsons bject to workman's compensation laws of California." The applican u caeq r i s i ns. Complete drawing on reverse side. Signed X Title: _ Date: JAM RTMEN E ONLY �1 Application Accepted b t Area /«. — ❑ Stk 466-6781 ` Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection byDate —f F-1Tracy 835-6385 e t Applicant - Return all copio: Environmental dealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 4 14-26 r