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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin ' Local Health District. Job Address Ed & Darlene Zaharis city Lathrop - Lot Size 33 Acres PM . 3637. Wast Stewart Rd sorra 953-1105 Owner's Name Address Phone Contractor Clark Well & CquiRddress 2024,-East CharterLicenseNo,371560 Phone 46.2-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT)Q( DESTRUCTION a PUMP INSTALLATION>C3( SYSTEM REPAIR ❑ OTHER ❑ V DISTANCE TO NEAREST: SEPTIC TANK 1 1 5 t SEWER LINES DISPOSAL FLD. PROP. LINE 17 5 t 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4 Dia. of Welf Casing 6 5/8" LTJ Domestic/Private "Gravel Pack ❑ Tracy Type of Casing pvc Specifications C 1 125 ❑ Public ❑ Other M}[lelta Depth of Grout Seal 501 Type of Grout 9 s a C k a i ❑ Irrigation ---Approx. Depth ❑ Eastern Su ace Seal Installed by Clark Repair Work Done ❑ Type of Pump Sub H.P. 1 1�2 State Work Done-M O V e to new well Well Destruction +J( Well Diameter 6" Sealing Material (top 501 9 sack Depth 70 Filler Material {Below 501 9 sack TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 CapacityNo. 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 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."Contractor's hiring or sub-contracting signature certifies the following:"I certify rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican call r 11 it spa . C to drawing on reverse side. Signed X Title: V p Date: 25 Feb 1987 FORD PARTMENT USE ONLY Application Accepte y -2111 Date Area r A&� Pit or Grout Inspec' y Date Final Inspection by Date,Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ nteca 823 7144 ❑ Trac 835-6M 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 CK 4 CASH RECEIVED BY DATE PERMIT''NO. + EHH 3-24 1428+REV.1/e 5) t 19-7~ g 7-3Jf 4