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r f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. I, 727 Windsor Cit S Lot Size 60 'XI -fin 1 PM Job Address I Y—��rF1 -v�ls�L-r�-•--- I Owner's Name Jc r-y & WP1 rh' AddressPhone i Contractor Clark Well, InCAddress 2024 E. Charter License Ni37_1_9_6Q_ Phone l - TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION Xk SYSTEM 'REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Nene_ SEWER LINES 9 OCI I DISPOSAL FLO. PROP. LINE 10 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ 1.2" Dia. of Well Casing65 8 11 XDC3JomesticlPrivate k-kGravel Pack ❑ Tracy Type of Casing PVC Specifications CL 160 M Public I❑ Other ❑ Delta Depth of Grout Seal 1001 Type of Grout Ben-ton i=_�te_ I i Irrigation ._.._.Approx.,Depth I ] Eastern Surface Seal Installed by Clark Repair Work Done El Type of Pump Sub H. P. 34 State Work Done-i ri s ta1:} Tv Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I I 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS i I Depth I Size Number SUMPS ❑ Distance � nearest: Well Foundation Property Line I DISPOSAL PONDS El 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 in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant all all d i petions. omplete drawing on reverse side. Signed X Title: VP Clark Well Data:26 June 90 all'Oft\DEPARTMENOr V T USE ONLY ! Application Accepted by hate t��+o � /� Area . Pit or Grout Inspection by ,/Date 4 Final inspection by��> `-� Date Additional Comments: 5141 4_10 (ifG��S� lt7a� et,i JCS ,..��. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Enviror;mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 I FEE t INFO AMOUNT DUE AMOUNT REMITTED C SH CK 4 R EIVED Y OATS PERMIT NO. a.EH 13-24(REV.IIK5) � b� r�_ P6_D /` I�� - ` EH 14-26 (((�� CS/ dd C! J