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APPLICATION FOR PERMIT r) SAN JOAQUIN LOCAL HEALTH DISTRICT S � 0 1601 E. HAZELTON AVE., STOCKTON, CA Al.1 Y u \ � Telephone 12091 468-6781 11/� ro tPERMIT EXPIRES 1 YEAR FROM DATE ISSUED s (Complete in Triplicate) 1 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin j Local Health District. Job Address 2147 Bowman City Stkn tot Size 50 acres PM jOwner's Name Rob i n s an Pa rm s Address 7000 Inland Phone - 1 , Contractor Clark WP1 1 Address License NO-3-71 560 Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT I DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 60 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-641— PITS/SUMPS INTENDED USE TYPE: OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 2'T Dia. of Well Casing 6 5411 XR)Pomestic/Private XkkGravel Pack ❑ Tracy Type of Casing P1717 _- Specifications CL 1 60 F] Public n Other jI Delta Depth of Grout Seal 30 , Type of GroutB8- � - i��vrrcr ,v-' I i Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Cl ;ar_k Repair Work Done ❑ Type of Pump &'1 h H.P. 1 S State Work Done_i p gt 3 I_1 K) Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other i Number of living units: Number of bedrooms Character of sail 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 y} FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS C Distance to nearest: Weil 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 I certifies the following;"I certif hat in the performance of the work for which this permit is issued, I shall em to p y persons subject to workman's compensa- tion laws of California." The appliA40/ ed i io s omplete drawing on reverse side. 1 Signed x Title; VP Clark Well Date; 24 Aug 89 FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by _�a L. eDate Final Inspection by <-- Date ` t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH -24(REV.r i n 51 14 r EH 14.28