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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District f&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 Re ulations of the San Joaquin Local Health District. —4,-3 Q -3.5 iE,, 4500 ft2 Job Address r � City Lot Size PM Owner's Name Address Phone 522 9472 Contractor 'Clark Well Address 2024 East ChartPr License No371 Stift Phon62-7676, TYPE OF WELL/PUMP: NEW WELL}a WELL REPLACEMENT ❑ DESTRUCTION ❑ J PUMP INSTALLATION F1 SYSTEM REPAIR 71 OTHER L1 DISTANCE TO NEAREST: SEPTIC TANK-1 5.(_ SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n 1 14 Gravel Pack to 3 [`'.'A] 171❑ Industrial Open Bottom EI Manteca Ria. of Well Excavation " Dia. of Well Casing rr ❑ Domestic/Private XXXMavel Pack ❑ Tracy Type of Casing Steel Specifications .250 N }{R Public F_1 Other C 1 Delta Depth of Grout Seal E;Q ' Type of Grout q g g r I I Irrigation _-Approx. Depth l I Eastern Surface Seal Installed by otters _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 iNo septic system,permitted.if public sewer is Y y t. L` k r ...,available within 200 rest"1 L i .L 1:•': N E Q'.a c±E.i T) i f-,k h (�c't "Up'!. �1 c ' 5 Installation will serve: Residence. Commercial Other Number of living units: Number of bedrooms 7 0 E ;�I x>��i �• �:j .Cir_,�t u � 'v 94 � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK'I a 1, }< 0, Type/Mfg i n _' �_ 17-_-. C Capacity No7 Coinpartments •+ 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 SEEPAGE PITS i I Depth Size Number S r) `O SUMPS L]"'"Distance to nearest: Well Foundation Property Line L K DISPOSAL PONDS ❑ 7J L� gat' 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 Diltrict. 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 become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion laws of California." 1 Theapplicant f al qui s c n C 'mplete-drawing-on reverse side. Signed X Title:VP Clark Date: 5 May 89 FOR DEPARTMENT USE ONLY Application Accepted by Date i L' u 1 Area Pit or Grout Inspection b Date Final Inspection by Date p(1� �` � Additional Comments: '11u�.V ❑ Stk 466-6781 ❑ Lodi 369- ❑ Manteca 823-7104 ❑ racy 835 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED-BY DATE PERMIT'NO.' INFO CASH t EH EH 14-2e 1,.�