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APPLICATION FOR PERMi7 SAN JOAQUi,'' LOCAL HEALTH DISTRICT 7 1501 E. HAZELTO( AVE_ NSTOCKTCN , CA PERMIT NO.Telephcri DATE ISSUED 1a-a-7-x3 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 874 E. Woodward Subdivision Name Owner's Name Brawn Sand Inc. Address 874 C. Woodward Phone 239-4929 Contractor's Name Clark Well, License No. 371560 Phone 462-5597 TYPE OF WELL/PUMP WORK: NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION 4C] PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK -+15 0 f SEWER LINES DISPOSAL FLD. PROP. LINE ♦10 1 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V" l� Industrial U Open Bottom X K)GManteca Dia. of Well Excavation 14 3/4 11 IL kA- Domestic/Private ,n Gravel Pack El Tracy Dia. of Well Casing 10 3 Z4" W ❑ Public F—j Other Delta Type of Casing • 988 Steel 71 irrigation Approx. ❑ Eastern [Cathodic Protection Depth Specifications L]Geophysical Depth of Grout Sea sack SO n me nt Type of Grout Other Surface Seal Installed by C l a r k Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) �] Installation will serve: Residence _ Commercial Other r Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. L] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE IJ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size 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 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 empl erson ;n such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contras ing si r ertifies the following: "I certify that in the performance of the work for which this permit is issu d, I shall y per ns a jest workman's compensation laws of California." The applicant s call o al r 'r i ec S. Complete drawing on reverse side. Signed X ;tle: VP—Clark- Well Date: 7 Dee 1483 FOR DEPARTM USE ONLY Application Accepted by ,,,� Area - Stk 466-6781 Additional Comments: 1J Lodi 369-3621 Pit or Grout Inspection by W(TIOA Date :c Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copies to: Envit4nmental Health Permit/Services 1601 E. Hazelton ve., P.O. Box 2009, Stk., CA 95201 FINFO BA�AMCUNTAMOUNT REMITTED RECEIVED BY DATE PERMIT N0. L� �? 3 B 3 - 13 7'S1 EH 13-24 REV. 10/82 10/82 500 14-26 t;b � G�ArI= l./GII Lv,7r �d�I LrVT.vo 4 s o y e" 0-- ✓/'°vim' ��-