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I t `= `a °, -•�' APPLICATION FOR PERMIT fSAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. i Job Address Bed ford & Ed i sr-in City Lot Size A PM Owner's Name Cal Water Service Address 1 1 1 1 N. El Dorado 466-8971 � Phone Contractor's Name Clark We 11License No. 3 71 5 6 0 4 6 2—7 6 7 6 TYPE OF WELL/PUMP: NEW WELL phone WELL REPLACEMENT ❑ DESTRUCTIOWW .PUMP INSTALLATION C1 SYSTEM REPAIR ❑ f DISTANCE TO NEAREST: SEPTIC TANK OTHER 11rt SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑'Open Bottom p Manteca Dia. of Well Excavation Cl Domestic/Private Gravel pack ❑ Trac ..Type Dia. of Well Casing 1 Y of Casing Specifications Ll Public ❑ Other El Delta Depth of Grout Seal E) Irrigation � Type of Grout ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done WeILDestruction ❑ Well Diameter 1611 Sealing Material (top 50'I 9 Sack Mix Sand & Cement ► Depth 545 Filler Material (Below 50') Same. (`` D j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ } # DESTRUCTION Ll (No septic system permitted if public sewer is \�JJ `is "3T' ' f 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: SEPTIC TANK ❑ Type)Mfg T Water table depth PKG. TREATMENT PLT. ElCapacity No. Compartments - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LiNE ❑ No. & Length of lines L Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: DISPOSAL PONDS F71 Well Foundation Property Line ' 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub- ontracting signature'. certifies the followi ity that in the performance of the work for which this permit is issued,I shall employ tion laws of Calif rn' ". p y persons subject to workman's compensa- The applican f a it d ins pe tions. Complete drawing.on reverse side. Signed Title:- .VP Clark Well Date: 21 July1988 _ EP �TUSE�,ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by // Z Dated�� Additional Comments: � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ID Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY 'DATE PERMIT No. EH 13-24(REV.10!831 3�• —�� EH 14Z8