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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escrbed. 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 Re�u! t' sof the San Jo quin Local Health District. 1T t 0 1 a Job Address 4100 N DuncanPM City�-indan Lot Size�C-�C5 Owner's Name Harriet Habeeb Address 1408 Lincoln Stockton 4628193 Phone Contractor's,Name,Elark Well $ Equip License No. 371560 Phone 462-5597 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Cl PUMP INSTALLATION q t SYSTEM A1R El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINE 1 DISPOSAL FLD. PROP. LINE 33 FOUNDATION AGRICULTURE WELL 1 5 t OTHER WELL 15 PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION C1Industrial Open Bottom 1-1 Manteca Dia, of Well Excavation Dia. of Well Casinq(�tt g, ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing 5 t e e 1 E9 Specifications `L ❑ Public ❑ Other ❑ Delta Depth of Gout Seal na Type of Grout -1VIrrigation - Approx. Depth ❑ Eastern - .Surface Seal Installed by a Repair Work Done ❑ Type of Pump Turbine H.P. 75 State Work Done re—install Weli Destruction ❑ Well Diameter Sealing Material (top 501 " Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is In will serve: Residence_ Commercial; Other available within 200 feet.) U Number of living units: Number of bedrooms (� Character of soil to a depth of 3 feet: a Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments `�•� T PKG. TREATMENT PLT. ❑ Method of Disposal " Distance to nearest: Well Foundation Property Line LEACFNNG LINE ❑ No. & Length of lines Total length/size- -FILTER BED Cl Distance to nearest: Well Foundation - - Property Line SEEPAGE PITS ❑ Depth Size Number fi SUINPS ❑ 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 shall not employ any person ifr c manne become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature (n certifies the following: 'hcertify that in rformance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of C o ia.' , The applica t c o I s ti s. Complete drawing on reverse side.- Signed Title: _ VP—Clark Well Date: 3 July 1985 FOR DEPARTMENTUSE QNLY Application Accepted by Date 7—Z3 'Fi Area d_ ` Pit or Grout Inspection by Date Final Inspection by 1/ i'-7� n Date_ &4_61V Additional Comments: 8 ❑ Stk 466 781 ❑ Lodi 3621 lo PAnteca 7104 ❑ Tracy 835-6385 P fi Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95209 FEE AMOUNT DUE AMOUNT REMITTED' CK RECEIVED BY DATE PERMlT"NO. INFO CASH EH 1 -24(REV.ia831 EH 1426 ' �/ � �5 _% k �, f � t _� 4 �