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APPLICATION FOR PERMIT R 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 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 6302 F6ppiano City Stkn Lot Size40 Acres pM Owner's Name Joe Solari Address same phone 9 31 1 7 6 5 Contractor Clark Well Address 2024 E. Charter WayLicense No. 371 560 Phone 462 7676 TYPE OF WELL/PUMP: NEW WELL PA WELL REPLACEMENT F1 DESTRUCTION ❑ PUMP INSTALLATION SSTE REPAIR ❑ rt (� � ' ❑ DISTANCE TO NEAREST: SEPTIC TANK M SEWER LINES / DISPOSAL FLD. PROP. LINE +500 r FOUNDATION' .5�_ AGRICULTURE WELL ��OTHER WELJ--V-ar PITS/SUMPS , Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial )d3t Open Bottom ❑ Manteca Dia- of Well Excavation 4 n Dia. of Well Casing 12 3 Z 4" ❑ Domestic/Private :-r,Gravel Pack ❑ Tracy Type of Casing_ Steel Specifications. 18 8 h 171 Public (_1 Other D Delta Depth of Grout Seal None Type of Grout--- "rrigation rout _"rrigation _-Approx.nth I I,Eastern Surface Seal Installed by Clark _ Repair Work Done ❑ Type of Pump ffWi1� H.P. 30 State Work Done T L Well Destruction ❑ Well Diameter Sealing Materia! Stop 501 Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION 11 (No 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE Cl No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS i I Depth Size Number j SUMPS D 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 Dstrict. 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 inoar as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following certify th in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws Aat ni The eppli. oraRirod C mplate drawing on reverse side. Signed X Title:VP Clark Date: 17 A U 9 19 8 8 FOR DEPARTMENT USE ONLY Application Accepted by __ S�S��rr Date s SR Area Pit or Grout Inspection by Date Final Inspection by Dates' Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 El Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK C 4f RECEIVED BY DATE PERMIT'NO. r.EH 13-24 IREV.1/H 51 L4 N9-X � EH 14-28 i l'$—4%Ll t5