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± APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 4924 Ashley Lane City StocktonLotSize PM Owner's Name Douglas Huggins Address 4155 E Waller Road Phone 931-3507 Contractor Clark Well, Inc. Address 2024 E Charter Way License No. Phone Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i"1 Public n Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Su ace Seal Installed by Repair Work Done ❑ Type of Pump Sub H.P. i.1,2 State Work Done Installed Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I 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 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 SEEPAGE PITS I 1 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 re tions of the San Joaquin Local Health Di§trict. Home own 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 ars n in suc ner s to beco a subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the ollo ing: "I rtify th in the pe rmance the work for which this permit is issued, I shall employ persons subject to workman's cornpensa- tion laws of a ornia.11 The applican t call for d s . Co late dr wing on reverse side. Signed X Title: Sec—Tre S Date: 6 March 90 OR DEPARTMENT USE ONLY Application Accepted byDJV ate .3.� Area Pit or Grout Inspection by Date Final Inspection by �' � '�z �L�/ Date 5 3o !C 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 FEE INFO AMOUNT DUE AMOUNT REMITTED I C SH RECEIVED BY DATE PERMIT NO. + EH 1 -24►HEV.r i n e) EH 144-28 �a