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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED I (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 I made in compliance with San Joaquin County Ordinance Nb.'549forsewage or No. 1862 for welt/pump and the Rules and Regulations of the San Joaquin Local Health District. ' Job Address Cit Y-Lt��-1 Lot $IZB +2QPM_ �nroo Owner's Name Sebastiani Vine and Address kD_Box AA S Phone 3 q Contractor Clark Well Address 2024 .:E: Charter StkriLicense No.371 560 Phone462-7676 TYPE OF WELL/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 1 ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well ExcavationDia. of Well Casing +` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I I Irrigation —..Approx. pepth I I Eastern Surface,Seal Installed by Repair Work Done ❑ Type of Pump!Turbine H.P. _1:00 , Skate Work Done ins ta11 E19ina Dr I Well Destruction E2Well Diameter Sealing Materid(top 50') _ _Turbine Fire. PumP in 16" Weiv Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is E Installation will serve: Residence— Commercial— Other' available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity p Y No. Compartments PKG. TREATMENT PLT. ❑ - - Method ofYDisposal Distance to nearest: Well Foundation ,r7 .'. a Property.-Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to 1nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth I Size _ Number SUMPS 0 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 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 California." The applica call f all re i d in r Co I e drawing on reverse side. i Signed Title: VP Clark Wel] Date: .4 Jun90 F. DEPARTMENT USE ONLY Application Accepted by Date Area3"J" f Pit Grout Inspection by Date Final Inspection by. fj/1 ] _,, Date # Additional ional Comments: i ' ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CK RECEIVED BY DATE PERMIT'NO. + EH 14.29(REV.7 i x 51 ;�� S./` [J lJ pD 1. 4