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f . APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT NO. Telephone (209) 466-5781 ' 2 DATE ISSUED 3 3 PERMIT EXPIRES i 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, Job Address 360'1 Parti fi .� Aug—linp Subdivision Name BUrE1S �QtJBT Regiorb Owner's Name UOP I Address 3601 Pacific Ave Phone 9462541 Contractor's Name Clark Well & EgUip6icense No. 371560 Phone 462-5597 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION l PUMP.INS{ALLATION E] SYSTEM REPAIR, _ OTHER L"1�aise pump lF] Uitutltl Vel DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER'LINES D'ISPCSAL FLO. PROP. LINE y u FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS plj INTENDED USE TYPE DF WELL PROBLEM AREA S CONSTRUCTION SPECIFICATIONS ' Industrial U Open'Bottom Manteca 'Dia. _of Well Excavation jJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public 1 Other Delta Type of Casing jJ Irrigation Approx. ❑ Eastern � Specifications Cathodic Protection Depth _ # e ' Depth of Grout Seal ❑Geophysical Type of Grout ¢ ❑OtherSurface Seal Installed by _Clark Repair Work DoneType of Pump urbineH.P, ` State Work Done raise pump—CC)j.Tpac.tpit Well Destruction U Well Diameter}! Seal ing.Materiaj(top 501) Depth 1 Filler Material (Below 50') W ,. 6"^ t TYPE OF SEPTIC WORK: NEW INSTALLATION Lj REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is � } available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: 9 Number of bedrooms Lot size Character of soil to a depth of 13 feet: -t Water table depth SEPTIC TANK Lj Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION Ie LEACHING LINE U No. & Length of lines Total length/size L FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS jTj Distance to nearest: . Well Foundation Property Line' h DISPOSAL PONDS # If F 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. N 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 an erson in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or sub g , nature certifies the following: "1 certify that in the performance of the work for which this permit is issued, al em loy o sub' ct to workman's compensation laws of California." a The applican u cal r a i d i.:s ec ons Complete drawin on reverse side. Signed X Title: VP—C�.ark Well Date: 3 Aug 1983 FOR- DEPARTMENT USE ONLY F Application Accepted by Area + ( Stk 465-fi781 Additional Comments: V Lodi 369-3621 Pit or Grout Inspection by ate Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all o es. to Environmental Health Permit/Sere es 1601 E. Hazelton Ave., P.O. Box 2D09, Stk., CA 95201 r FEE BASE AMOUNT., DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO � �3—3 'y2--.1-1 F EH 13-24 REV. 10/82 10/82 500 14-26 "r