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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 6W 1,42 + (Complete in Triplicate) 059 cation is construct /or install the work .This appl Application is hereeYNdSanothe San Jo_aquirr County Ordinance No.549 for sewage oruin Local Health District for a 'No�1662 for well/pump and the Rules and herein Regulations of he San f Joaquin _- made in compliant °i Pre-72 Local Health District. t : 10 AS cr PM City Lot Size I Job Address Y ! 62--2282 David Grillo 3535 N. Pershing e Owner's Name Address 202 East Charter 371.560 Phone -- Contractor Clark Well Address License No._ Contractor TYPE OF WELL/PUMP NEW WELL)CI WELL REPLACEMENT ❑ DESTRtfCTION EI PUMP INSTALLATION IX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO tJEAR1 ST: SEPTIC TANK +1,004 SEWER LINES DISPOSAL FLD. ' PROP. LINE`IQd FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr Dia. of Well Casing f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation #.2 M Domestic/Private )I Gravel Pack ❑ Tracy Type of Casing C+___�P_P 7- — Specifications Type❑ Other T of Gtout T pack [`l Public Ci Delta Depth of Grout Seal 7_fl — E f i I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by C Laxk — Repair Work Done LI Type of PumpLL�] H P 3 State Work Done In S*^� � i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material tBelow 50'I TYPE OF SEPTWORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I.1 DESTRUCTION I I availablelosetic cyst m parm feet.) Hed if public sewer is IC Installa I I serve: Residence_— Commercial— Other Number of living uni Number of bedrooms r Character of soil to a depth of 3 Water table depth tr` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal I { Distance to nearest: Well Foun Property Line T i LEACHING LINE ❑ No. & Length of lines Total iengt � FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS I I Depth Size Number R i SUMPS L1 Distance to nearest: Well Foundation Property Line - � DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and I rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "f certify that in the performance rn the work for which this permit is issued, I shall not employ any person in such manner to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature certifies the following:"1 certify t t in the r10 ante of he work for which this permit is issued,f shall employ persons subject to workman's compensa- tion laws of Calif nia." The applican r re c m to dra ing on reverse side. 2 Sept 1987 i Signed X ills: VP-Clark Well Date: P :F71)EPART11MErN,1T1 USE ONLY �r C Date /�z 6 Area /01 Application Accepted b t Date F. nspection by Dated Pit or rout Ins do rat/in Ad rt(onat Comrnt . T ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Appli = Return all copies tow., Environm ntal Health Permit/Servrc s 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 trr 1 � _ Cox, (f Jts _ {� FEE CK RECOFD Y DATE PERMIT'NO. 1 V I INFO AMOUNT DUE AMOUNT REMITTED CASH ♦ EH 13.24(REV.rixet IEM 14-25 - -