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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT < fps \,j/ 1601 E. HAZELTON 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 5 RR 01 FI y�� + City� T, Lot Size PM Owner's NameDelta Development Address POBox 7414 Phone 474-081 7 Contractor Clark Well Address 2024 E. Charter License No.-471 S 6 0 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION { SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'jam fl ' SEWER LINES DISPOSAL FLD: ()() I_ PROP. LINE —+O_r FOUNDATION AGRICULTURE WELL OTHER WELL--3-5-1— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11 Dia. of Well Casing 6tr }Domestic/Private R%Gravel Pack ❑ Tracy Type of Casing PlIr Specifications CL 16 0 M Public ❑ Other ❑ Delta Depth of Grout Seal n r Type of Grout gsack I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by Clark Repair Work Done ❑ Type of Pump S1—o11h H.P. 2 State Work Done instal: \J Well Destruction [I Well Diameter Sealing Material (top 50') Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 Q 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 n 4 SEEPAGE PITS I I Depth Size _ Number SUMPS Ll 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: "1 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." 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 C rni The applica t I or 11 ire i t ns Complete drawing on reverse side. Signed X Title: VP Clark Well, Inc. Date: 1 ; Aug 1 ()RA FOR DEPARTMENT USE ONLY Application Accepted by L IQ Date '� Area Pit or Grout Inspection by Date Final Inspection by / Date 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 Nw; FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED BY (� DATE PERMIT'NO. + EH 13-24►REV.1/x 5) \� �l / EH 14-26 ` U x- 19-7Yop