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APPLICATION FOR PERMIT SAN,JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ` Telepkone (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 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 22570 E. Highway 4 city FarmingtonDt Size 100. acres PM Owner's Name George Lagorio Address 2771 e French Camp Rd Phone 982 0734 Contractor Clark Well Address 2024 E. Charter License No371 560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ m PUMP INSTALLATION [k SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.+300 t PROP. LINE FOUNDATION AGRICULTURE WELL _4a_!._ OTHER WELL 'Y PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial XkOpen Bottom ❑ Manteca Dia- of Well Excavation 16 rr Dia. of Well Casing 16rr 1 ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing S t-PP_1 Specifications .250 M Public F1 Other f 1 Delta Depth of Grout Seal NA Type of Grout _ Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Grath _ Repair Work Done ❑ Type of Pump TtT�ne H,P. 100 State Work Done install Well Destruction LJWell Diameter Sealing Material (top 501 1� 4 Depth Filler Material (Below 501 V1 TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is" " available within 200 feet 1 Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms E Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number t 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 shall riot 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 Calif nia." The applicant t c r r it spec ns. Complete drawing on reverse side. Signed x Title: VP Clark Well Date: 21 March 89 ; FOR DEPARTMENT USE ONLY Application Accepted by Date 21-17 Area 1 C, Pit or Grout Inspection by Date Final Inspection by Date-? 2/4 Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE I AMOUNT REMITTED GASH RECEIVED BY DATE CK 0 PERMIT�NO. +.EH 13-24(REV.tin 51 � lr Ek 11-28T5b S–�r� s