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APPLICATION FOR PERMIT /��l SAN JOAQUIN LOCAL HEALTH DISTRICT S��a,r/�i�11NED 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 Ot City S tv_kCp_}- Lot Size PM .- Owner's NameDelta Development Address PO BOX 7 41 4 Phone 474-081 7 Contractor Clark Well —Address--2024 E. Charter License No-371 560 Phone 4 F;9-7676 TYPE OF WELL/PUMP: NEW WELL kb{ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION kA SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK --a(]4 ' SEWER LINES DISPOSAL FLD1 PROP. LINE 10 FOUNDATION AGRICULTURE WELLOTHER WELLS r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation tt Dia. of Well Casing rr }i�:Domestic/Private ��ravel Pack ❑ Tracy Type of Casing plic Specifications CL 1 6 0 FI Public ❑ Other n Delta Depth of Grout Seal _T�O - Type of Grout �aC-k.,__ I I Irrigation _.-Approx. Depth I i Eastern Surface Seal Installed by-_ Clark-- -crrl,,.t, - -i �— Repair Work Done ❑ Type of Pump slih H.P. 2 __-_ State Work Done: n_ _, , i iiia�.ai. DO Well Destruction ❑ Well Diameter Sealing Material Itop 501 Q Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I i DESTRUCTION l 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 Cl No. & Length of lines Total length/size FILTER BED I] Distance to nearest: Well Foundation Property Line N 0 SEEPAGE PITS i I Depth Size T 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 Di"strict. 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 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 II ire i t' ns Complete drawing on reverse side. Signed X Title: VP Clark Well, Inc. Date: 15 Aug 1 989 FOR DEPARTMENT USE ONLY Application Accepted by Date 1� Area Pit or Grout Inspection by Date Final Inspection by ' / Date ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 4 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY (�1 DATE PERMIT'No. . EH 13-241REV.1/nsl ` , 117 EH 14.26 U Q p