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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZETON AVE., STOCKTON, CA l Telephone (209) 466-6781 k f PERMIT EXPIRES 1 YEARFROM 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. IB62 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. t " Job Address 1 380 Frewert t City Lathro Lot size 59 acres PM Owner's Name Address _,came Phone none Contractor Clark Well -Address 2024 F_ Charter Way_License No.371560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENfCJIZX DESTRUCTION ❑ PUMP INSTALLATIOI kX SYSTEM REPAIR ❑ OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK 75 ' SEWER LINES DISPOSAL FLD. PROP- LINE +1 00 r FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I &a. of Well Casing 6 S 8If Domestic/Private L,�,kravel Pack ❑ Tracy Type of Casing PVC - ke cifications CI 1 60 M Public F1Ot FI Delta Depth of Grout Seal Ir-+ of Grout i I Irrigations pprox. Depth l I Eastern Surface Seal Installed by- C 1 ark _ Repair Work Done ❑ Type of Pump Sub H.P. 1 State Work Done i)a 2ta11 Pump 111 Wel I Well Destruction ❑ Well Diameter Sealing Material (top 50') hookup by Owner f ! Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIRIADDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is t 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 tA a SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well foiindation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size - FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line [ DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and ' rules and regulations of the San Joaquin Local Health District. Homeowner 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."Contractors 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 emptoy persons subject to workmarils compensa- tion laws of Califf ni The applicant st a for Ire d s s. Co plate drawing on reverse side. Signed X Title: VP r1 ark Wel 1-2... - Date: 14 Sept.- -� R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or rout nspection byDate Fi` I Inspection by D � Additional Comments: AL� ❑ Stk 466-6781 ❑ Lod'+ 369-3621 ❑ Manteca 823-71 ❑ Tracy/836-6385 Applicant - Return all copies to: Environmental Health Perm't/Servicas 1601 E. Hazolton Ave., P.O. Box 2009, Stk., CA 95201 )FEE NFO AMOUNT DUE AMOUNT AMITTED CK RECEIVED BY DATE PERMIT'NO. J +.EH1 -241REV.i/nsl \ Q� Il 2 � EH 144-26 1 l D`I r