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WF11 APPLICATION FOR PERMIT S ��,o Fy SAN JOAQUIN LOCAL HEALTH DISTRICT ' (J 1601 E. HAZEL T ON AVE., STOCKTON, CA 1� 09 Telephone l2 1 466-6781 ; PERMIT EXPIRES TYEAR FROM DATE ISSUED t/S 1 (Complete in Triplicate) (�JL I`' Application is heieby 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. 2147 BowmanCity Stkn Lot Size 50 acres PM . � Job Address Owner's Name Robins on_ Farm- Address 7000. Phone 4 63- Contractor Cl irk 90-11 Address License No. Phone 46276 7-6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTIX, DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 6 0' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing Specifications CL 1 �� XRl�omestic/Private X)&Gravel Pack ❑ Tracy Type of Casing PVC' f`l Public F1 Other j1 Delta Depth of Grout Seal 3()_L_ Type of Grout Be-,t-onj- -e, { I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by f l r - Repair Work Done 0 Type of Pump Sub H.P. 1 . S State Work Done in.c i-a 1 1 Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material IBelow 50`) -- TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION I l INo septic system permitted if public sewer is available within 200 feet.i 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 h SEEPAGE PITS I I Depth Size Number " SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .'a 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§trict. E s permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thi 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 cartif that in th performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 11 1 f The applicant t It r It ed i io s omplate drawing on reverse side. Signed X r/ Title: VP Clark Well Date: 24 Aug 89 FOR DEPARTMENT USE ONLY IlaCFN4 Application Accepted by date Area ,. Pit or Grout Inspection by Date 6( O Final Inspection by Date $�f l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO +.EH 13-241REV.E/nhf EH 14-29 \\`��VVv C] CCC...!!!fff r�r - a ��0