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1 APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA l Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I 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 3 made in compliance with San Joaquin County Ordinance No.549 for,sewage or No. 1862 for welilpump and the Rules and Regulations of the San Joaquin Local Health District. ddresBowser Rd City Lackef0rci tot Sae aGTE:S'' Job A 17266 BoPM"y I owner's Name Mary Riley Address 9506 Knight Lane. Phone 474 5354 ... e Contractor Clark Address 2024 East Charter License No. 3.71560 'Phone 62 7676 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ " f PUMP INSTALLA11 TIONtC� SYSTEM REPAIR ❑ OTHER Ely DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES DISPOSAL FLD. " PROP.'ONE. 20P t, r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS: ; { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 t Dia. of Well Casing : F ;1 Domestic/Private NM Gravel Pack ❑ Tracy Type of Casing J' tee1 Specifications #1 0 1-1 Public FR Other ❑ Delta Depth of Grout Seal Sol Type of Grout Cebbnt _- 4 I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Clark Repair Work Done ❑ Type of Pump Sub H.P. 5 State Work Done _install e Well Destruction ❑ Well Diameter Sealing Material (top 50') t Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION f I (No±septic system permitted ifpublicysewer is v .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 ❑ TypelMfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Mgthod of Disposal ! Distance to nearest: Well Foundation Pwpea Line LEACHING LINE ❑ No. & Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; SEEPAGE PITS I I Depth Size Number SUMPS ❑ ~Distance to nearest: Well Foundation Property Line " DISPOSAL PONOS ❑ I 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 I rules and regulations of the San Joaquin Local Health District. 1 Home owner or licensed age gnature ifies 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 nner as to beco su ect to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the following: "I c ify t t in the o e of the ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal-orn' The applican II re ui d spec o to rowing on reverse side. Signed Title: VP--C1ARK Date: 22 Feb 1988 TNlENT USE ONLY s M"EeA Application'Accepted by r Date Area cr �7 Pit or Grout Inspection by C� Date G r Z�-��Final Inspection by Pate i k Additional Comments: ! f{ ❑ 5tk 466-6781 ❑ Lodi 369-3 ❑ Menta7104 Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/ ervices 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95201 FEE K 6 INFO AMOUNT DUE AMOUNT REMITTED �CAOSH RECEIVED BY DATE PERMIT'NO, + EH13-24(REV,1 i n s) 'r�il J0 EH 14.26