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APPLICATION FOR PERMIT SAN JOAOU;N LOCAL 'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 93 Telephone (209) 466-6781 ••� DATE ISSUED * P� PERMIT EXPIRES I YEAR FROM DATE ISSUED � t��.1 S' uJ- �t Co.�'7— �-C l (Complete in Triplicate) SPC ComrAut %cwri6US 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 ,]odauin Local Health District. 'Job Address 1 mile W.I-5 11 Bile N 0 81Fi.il0diYdipn Name Owner's Name John Otto ,1 Address P.Ci.Box 2858 Sac. Phone;i916 441 -68 0� Contractor's Name Clark Well, & E q u 1p License No. 371Phone 462-5597560 TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,1_1 DISTANCE TO NEAREST: SEPTIC TANK *15 B t SEWER LINES DISPOSAL FLD. PROP. LINE ~ FOUNDATION ` AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS , `lf Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 20" U'Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing 8 5/811 . ❑ Public ❑I Other. ❑ Delta Type of Casing 6 steel i I❑ Irrigation . Approx. ❑ Eastern 16 11 . oFl uc of- to 50t Specifications ❑ Cathodic Protection Depth Depth of Grout Seal 501 R ) I Geophysical Type of Grout Sqrk Mi X4.? U Other Surface Seal Installed by f'.1 ark fp Repair Work Done ❑ Type of Pump 81117 H.P. 1 0 State Work Done & tank Well Destruction ❑ Well Diameter Sealing Material (top 50') ^ F Depth I Filler Material (Below 50') �. TYPE OF SEPTIC WORK: NEW INSTALL-ATIDN [:I REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer'-is available within 200 feet.) Installation will serve: Residence Commercial Other F'. Number of living units: (Number of bedrooms Lot size Character of soil to a depth of .3.feet: Water table depth t i. SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal II SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line I DESTRUCTION c LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED E Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number t SUMPS ❑1 Distance to nearest: Well Foundation Property Line a DISPOSAL PONDS ❑ r 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, ] shall not employ any person in such manner as to become subject to workman compensation laws of California." I Contractor's hiring.or ub- tra ting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, sha lay persons subject to workman's compensation laws of California." The applicant c 1 r it inspections. Complete drawinon reverse side. Signed X Title: -- ark Well Date: 19 Aug 1983 , FOR EffPXIMENT USE ONLY Application Accepted by Area `, Stk 466-6781 111 Additional Comments: + ❑ Lodi 369-3621 Pit or Grout Inspection lby Date 7` ❑ Manteca 823-7104 Final Inspection by Dio�7� 56e- I Date 6 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. (NFD —leg— `S136 �lf. [,tJ QJ`C � � VZ/\ r EH 13-24 REV. 10/82 f 10/82 500 14-26