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APPLIC TION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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.Me for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2324 Navy Drive cit, Stockton Lot Size__ PM Owner's NameWeater State Steel Address 2324 Navy Drive Phone 944-9581 Contractor's Name Clark Well & EgUlRkense No. A-371560 Phone 462-5597 TYPE OF WELL/PUMP: NEW WELL W WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0J SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150 SEWER LINES 150 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 4Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 8 5/8" ❑ Domeadc/Private Gravel Pack ❑ Tracy Type of Casing Ste 01 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 15 Irrigation 1 15 G—Approx. Depth ❑ Eastern Surface Seal Installed by Clark Well Repair Work Done ❑ Type of Pump SLI] H.P. 3 State Work Done—Install U/ Well Destruction 71Well Diameter Sealing Material (top 50') rf Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Cl (No septic system permitted if public sewer is J available within 200 feet.l C� Installation will serve: Residence_ Commercial_, Other Number of living units: Number of bedrooms G Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line , v LEACHING LINE ❑ No. & Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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."Contractors hiring or subcontracting signature certifies the foll ing: "I certify that In the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C mia." The applicant t call for al r ired s ctions omplete drawing on reverse side. Signed Title: Sec—Tres Date: 17 June 1985 FOR DEPARTMENT USE ONLY Application Accepted by Dare Area T— Pit or Grout Inspection by Date Final Inspection by Date IQ. Additional Comments: Stk 466-6781 ❑ Lodi 3633621 ❑ Manteca 823.7104 ❑ Tracy 8358386 kk icant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 I� FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BV INFO '' / CASH DATE PERMIT NO. EH=(REV. 10/830 /� /t V-S EH 1425 /�/ `�/Ic �s