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Nw APPLICATION FOR PERMI" 1%� �-3-' �� SAN JOAQLi'; LOCAL HEALTH DISTRICT PERMIT NO. 1601 E. HAZELTON AVE., STOCKTON, CA DATE ISSUED I , • Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) y permit to construct and/or install the herein Application is hereby made to the San Joaquin Local Health District fora p described. This application is made in compliance with San Joaquin Count Ordinance No. 549 for sewagef th and the Rules and Regulations Of the T1 Joaquin Heal Subdivision Name 1 E• Norma 11931 E Norman, Stockton Phone 2_7 ' Job Address jig, Ahrens Address 0 Phone 1 Owner's Name C•E• Lil cense No. 371 5 1 cZ Contractor's Name C lark Well & Eq p' WELL REPLACEMENT ❑ DESTRUCTION ❑ NEW WELL ❑ OTHER ❑ TYPE OF WELL/PUMP WORK: SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION IRS DISPOSAL FLD. SEWER LINES PITS/SUMPS � DISTANCE TO NEAREST: SEPTIC TANK � AGRICULTURE WELL �_— OTHER WELL V FOUNDATION _�-- PROBLEM AREA CONSTRUCTION SPECIFICAT INTENDED E TY?E OF WELL Dia. of Well Excavati ❑Open Bottom ❑Manteca Industrial ❑Tracy of Well Casing ❑Gras-Y'Pack Domestic/Private ❑Delta Type of Casing ❑Public F-1er 16 Approx. ❑Eastern Specifications Irrigation Depth Depth of Grout Seal ❑Cathodic Protection Type of Grout ❑Geophysical Surface Seal Installed by Other _State Work Done l l new 3 Hp �1 Type of Pump ..�,,, _H.P. _y -- Repair Work Done Iz`-� Sealing Material (top 50') Well Destruction ❑ Well Diameter Filler Material (Below 50') blit sewer is Depth ermitted if pu REPAIR/ADDITION LJ septic tank or seepage Piavailable within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION LI Commercial ether Installation will serve: Residence _ _ Lot sizem units: �-- Water table depth Number of living Number of bedrooms No. Compartments Character of soil to a depth of 3 feet: Capacity Method of Disposal Type/Mfg Capacity SEPTIC TANK E] LType/Mfg Property LinePKG. TREATMENT PLT. EDWellndation —SEWAGE SYSTEM ❑ ance to nearest: - Total length/size DESTRUCTION _ Line LEACHING LINE LJ No. & Length of lines Foundation �- Property —--- FILTER BED ❑ Distance to nearest: Well �- Number Depth Size Foundation � Property Line SEEPAGE PITS ❑ �.--- _- ❑� Distance to nearest: Well - SUMPS ❑ DISPOSAL PONDS � have repared this applicationand that the work will be done nein District. with San Joaquin county I hereby certify that I ha P ulations of t that in the performance Of the ensationwork lawsfor which this of California." ordinances, state laws, and rules and reg Home owner or licensed agent's I certify that in the performance of the work for which ent's signature certifies the following: "I certify Permit o e issued, I shall not employ any Person in such manner as to become subject to workman comp Pe or sub-contracting signature certifies the followinensation laws of California." 2 Contractor's hiring persons subject to workman's comp 1 �Tt�l V 8 3 this permit is issued, I shall employ PClark Well Date: _ -� The applicant must call for all required inspections. Title: drawing r e8 arse side. A �Stk 466-6781 Signed X ARTMEN�)USE ONLY Area — — � ❑ Lodi 369-3621 Application Accepted by ❑ Manteca 823-7104 Additional Comments: to ��- —� Tracy 835-6385 Date — Pit or Grout Inspection by 95201 Final Inspection by s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box PERMIT N0.' C Applicant - Return a co RECEIVED BY DATE AMOUNT DUE AMOAMOUNT REMITTED2 .$ FEE BASE -7 '� U INFO 10/82 500 EH 13-24 REV. 10/82 1001, 14-26