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m APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone,12091 4W6781. . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - »„• . .¢ , - •-,: (Complete in Triplicate) l S`7�+�-� �" 1 "o4�.S Application is hereby made to the San laquin 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 Na.1862 for well/pump and the Rules Re/gtullagtions f thip Saraquin� Local Health District.. � � f mile east of athe °end of Sothern andFarmingttgl�t Size 100 acres PM Job Address Of sb-ani; City Owner's Name Margret Ehler TroinbelAla ass Po Box -'106 Farmington Phone . 866-5304 1 4625597 Contractor's Name Clark Well License No. 37156Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 12 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER , DISTANCE TO NEAREST: SEPTIC TANK-"' =-•N---SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION�'y AGRICULTURE WELL _ OTHER WELL PITS/SUMPS f INTENDED USE TYPE.OF WELL `PROBLEM AREA CONSTRUCTION SPECIFICATIONS t! ElIndustrial X Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing 16 i❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications *250— d ❑ Public ❑ Other ❑ Delta Depth of Grout Seal NA Type of Grout XK Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Clark Turbine H.P. 1017 State Work Done install Repair Work Done ❑ Type of Pump , )Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') I _ TYPE OF SEPTIC WORK: NEW INSTALLATION LJREPAIWADDITiON C] DESTRUCTION El (No septic system permitted if public sewer is 1� i available within 200 feet.) i 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 i C SEPTIC TANK ❑ Type/Mfg Capacity 1 ' � 3) No:-Compartments Ca aci PKG. TREATMENT PLT. D .1 Method 61,1XIsposal Distance ii ne�rest:�"Well""'""'°-�`"—Foundation ope�r'q,L'uie 3 f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i if SEEPAGE PITS ❑ Depth Size Number VSUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ \� 4 'I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county dances,state laws, and 1 rules and regulations of the Sari Joaquin Local Health District. ti � i Home owner or licensed age re certifies the following: "I certify that in the performance3f.the 1work for which this pdrmit,is issued;.)-shall not w employ any person in such nner as to ome subject to workman's compensation laws of Cal'rforma."Contractor's, hiring or sub-cvnfracting sig Aure certifies the folio g:"I ce t in th ante of the work for which this permit is issued,I shall employ persons subject to workmanfs compensa- i tion laws of C rn' i -- The applica II r a1 ui in c' om to drawing on reverseide: f k Title: C l ar k,Ws 1 _ P r* Date: --w Signed > f a t ,' i s f FOR DEPART NT USE ONLY s-Z3 ; t� Appli ion Accepted by Are t Date „� w 1 : ..Sr . `�` C Pit ro Gut spectivn by Date j _ '� Final Inspection by Date r #Additional Comments: ❑ Stk 466�i781 ❑ Lodi 369 3621 ❑'Manteca t.923-71'04". 'j j❑�T�acy x835 6385. L Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HazeltonBbx 2009„S_tk., CA 95201„ { A , �1 W 'r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE�� PERMIT`N0. EH 1324 IREV.101835 Lr EH 1429