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r � APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 11� r (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. B095 N. Rio Blanco Stockton 10 "aures Job Address City Lot Size PM i Paradise Point Marina sane 952-100 Owner's Name 1 Address Phone Contractor's-Name Clark `Well & EquiPL4 NQ. 371560 Phone 462-7676 + TYPE OF WELL/PUMP: NEW WELL YEJK WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER t❑ DISTANCE TO NEAREST: SEPTIC TAN 1501 1 50 t SEWER LINES DISPOSAL FLD1 1 rJQ PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 13 Open Bottom Cl Manteca Dia. of Well Excavation Tl Dia. of.Well Casing tT ❑ Domestic/Private XMGravel Pack ❑ Tracy Type of Casing PVC SpecificatioCIL 160 X>rublic ❑ Other X XIW VR1ta Depth of Grout Seat Fin t Type of Grou ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by _ nUnRr Repair Work Done ❑ Type of Pump, H.P. State Work Done 0a Welt Destruction El Well Diameter Sealing Material (top 50') 0 Depth Filler Material (Below 501 iSn TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V r # available within 200 feet.) Installation will serve: Residence—� Commercial— Other Z Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal .. U Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Len nth of lines I 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f _ SEEPAGE PITS ., ❑ Depth ( Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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— , rules and regulations of the San Joaquin Local Health District. 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 spLmlner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: I certify n the performance of the work for which this permit is issued, I shall employ persons subject-to workman's compensa- tion laws of Califomi The applic s ca o a eq e i ctions. Complete drawing on reverse side. Signed ' VP—Clark Well 11— 2—Bb— Date: j 9 Title: FOR DEPARTMENT USE ONLY } 7 Application Accepts y ��7A Date /i/-1c� 119-5- ,r Area f Pit or Grout Inspection by r Date,LLQ Fina! Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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"N0. .+EH 13-24{REV.101831 EH 1426