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a APPLICATION FOR PERMIT SAN JOAQ,UIN LOCAL HEALTH DISTRICT 1601 E._HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P (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 j 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. Ho 6 s t e a d Sailings Site # 1 1/2 mile` SouthSequioa & 11th Tracy Job Address City Lot Size PM Evans Bros 1624 Portola Ave 415-443-0225 Owner's Name Address Phone Clark Well 20324 E. Charter Way 371560 462-7676 Contractor Address License No. Phone TYPE OF WILL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 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 ❑ Public ❑ Other ❑ DeltaDepth of Grout Seal Type of Grout ❑ Irrigation --4pprox.'Depth ElEastern ` Surface Seal Installed by Repair Work Done ❑ Type of Pump �� H.P. SiaSa teo Done' Well Destruction � Well Diameter Sealing Material {top 50') " {C Depth `t /411 Filler Material (Below 50') 9 5ar.k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i 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, ❑ Type/Mfg Capacity No. Compartments 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 ❑ Depth. Size Number SUMPS ❑ Distance to nearest: Well - 7 Foundation Property Line DISPOSAL PONDS ❑ 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 such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- 4 tion laws of C Ilfor ia.l The applic c I II r re ti . omplete drawing on reverse side. I Signed X Title: VP—Clark Well Date: 20 July 1987 ; k 9LFOR DEPARTME T USE ONLY J i Application Accepted by � Date r Area Q� k Pit or Grout Inspection by Date Final Inspection by Date �� 1 Additional Comments: r ❑ Stk 466-6781 ❑ Lodi',369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201CK 0 FEE { INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMRT NO. + EH 13-24(REV.l/65) ~ - 1,2-dgFT7 EH 1428