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,. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Pre 1972 Lot of Record Job Address 4772 E Woodbridge Rd City_Acamr,po - Lot Size 1T2A-re_ PM Owner's Name Reuben & Janie Schlah Kddress Phone same 3695487 Contractor. Clark Well Address 2024 E. Charter License No.371 560 Phane462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CCK DESTRUCTION X PUMP INSTALLATION 31 SYSTEM REPAIR ❑ OTHER C1 DISTANCE TO NEAREST: SEPTIC TANK _ *551 SEWER LINES DISPOSAL FLD. PROP. LINE 15 1 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 2ir — Dia. of Well Casing6 5/811 XX Domestic/Private 1Gravel Pack ❑ Tracy Type of CasingSfiP0-1 Specifications #1 0 1'1 Public [7 Other ❑ Delta Depth of Grout Seal 'I S Il 1 Type of Grout 9__.-sack I I Irrigation _.-Approx. Depth l I Eastern SuVace Seal Installed by Clark Repair Work Done ❑ Type of Pump Sub H P 1 2 . State Work Done_ install Well Destruction XX Well Diameter 611 Sealing Material (top 541 Dep"th +80 Filler Material (Below 501 11 'T TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHtNG LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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 taws 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 tali all a fed s cti n Complete drawing on reverse side. - Signed Title. p Clark Date: 6 Oct 1988 FOR DEPARTMENT USE ONLY / Application Accepted by Date M)Imo- Area ti Pit or Grout Inspectionby Date Final Inspection by± Data 2�' �f. Additional Comments: ❑ Stk 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, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH13.24(REV.1/"5) EH 14-26 0 to— • I