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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 1-3993 South Airport Way City Lathrop Lot Size PM Owner's Name K j e lds en S innock Address P• 0. BOX 844 Phone 946-0268 Contractor Clark Well, Inc. Address 202 1' E Chrter Way License No. 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELT; ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERS/ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINA FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal T pe of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by UC QAL " _ Repair Work Done ❑ Type of Pump H.P. A State Work Done_Brin u t0 Code. Well Destruction ❑ Well Diameter Sealing Materia 6p50') Depth Filler M ial (Below 501 �,, Aw,,L _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AbDIT10N I I 'DESTRUCTION f9 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms w 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 7 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of livres Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 0 SEEPAGE PITS I I Depth Size _ Number SUMPS Ll 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 rentions of the San Joaquin Local Health Diltrict. Home own ror licensed a s signature certifies the folio ing: "I certify that in the performance of the work for which this permit is issued, I shall not employ an per n in sti ma ner s to b co subject to orkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foil ing: "I rtify in t or ance oft Work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws ,f rnia." The applic t s c o all re ed ns tin Comp drawing on reverse side. Signed X 1tl,. Sec—Tres Date: 3/5/90 FOR EPARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection by . Date-�12O 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 FEE INFO AMOUNT DUE /AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH13.24(REV.1/9 5) EH 1426PX-11I C, -S