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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 East; Foppiano Rd _ city Stkn Lot Size 30 acres .....PM owner's Name Joe Solari Address 6302 EastFoppiano Phone 931 1 765 Contractor's Name Clark Well- License No. -371 -960 Phone 4 2 7676 -% TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IN SYSTEM REPAIR ❑ OTHER ❑ Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL Q' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 5/8.11- Jl Domestic/Private ❑kGravel Pack ❑ Tracy Type of Casing Steel Specifications #12 ❑ Public Q Other ❑ Delta Depth of Grout Seal 50 Type of Grout 9 sack cem ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Clark r ' Repair Work Done jKf Type of Pump SllrH.P. 3 State Work Donei i- . Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C1 DESTRUCTION El (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 LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line of SEEPAGE PITS ❑ Depth Size Number 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, 1 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 t in the pe ante of the work for which thisermit is issued, I shall employ p p y persons subject to workman's compensa- tion laws of Californ' ." The applica calf r I i i cti o dr Ing on reverse side. Signed Title: VP Clark Well Date: 3-25-88 • FOR DEPARTMENT USE ONLY 1 Application Accepted by Date�:J A [/v Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: /� S ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �DATTE1/ PERMIT"NO. + EH 13-24(REV.19/83) ! EH 1428