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APPLICATION FOR PERMIT 0. SAN JOAQUIN LOCAL HEALTH DISTRICT Y l 1601 E. HAZE T ON AVE., STOCKTON, CA Note! ReDrawed Per Telephone (209) 466-6781 of 84-543 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 84-544 , (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. 3792 N. beeches . Stockton 10 acres Pre-1972 Job Address City Lot Size PM owners Name' Dots Ghiglieri Address 3636 N Beecher Phone 931-3367 Clark Well 371560 462-7676 Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION It SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK 50 O i SEWER LINES DISPOSAL FLD. PROP. LINE 30 FOUNDATION AGRICULTURE WELL OTHER WELL 500 t PITS/SUMPS -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial NK Open Bottom ❑ Manteca Dia. of Well Excavation 1n 114 It Dia. of Well Casing 11 ❑ Domestic/Private ❑ Gravel Pack - -13 Tracy Type of Casing S t e e l Specifications . , 18 8 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ALA Type of Grout XXIrrigation 25-0-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump duh H.P. 1 n State Work Done s t-a l I i Well Destruction ❑ Well Diameter Sealing Material (top 501 t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is F available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other I Number of living units: Number of bedrooms � Character of soil to a depth of 3 feet: Water table depth ` 1 SEPTIC TANK ❑ Type/Mfg Capacity No..Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 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 ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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 me subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in pe a the wo k for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant I for I ired ons. to rawi on reverse side. Signed e: VP—Clark Well Date: 15 Nov 1985 FO Application Accepted by R DEPARTMENT USE ONLY Date Area ::::� Pit or Grout Inspection by Date Final Inspection by f�J ate S 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 2000, Stk., CA 55201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ! PERMIT"NO. + EH 13-24 1REV.101831 EH 1426 G�l�