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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTf FrE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 10702 N Lower Sacramento Rd City Stockton Let size PIMJob Address Owner! DOCS Recreation Address 1 �,0702 N Lower Sacramento Phone Z7_7's Name Contractor Clark :Well, Inc. Address 2024 E Charter Wa—VLicense No._3 71_�_60 1 Phone462— 6 6 TYPE OF WELL/PUMP:;. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR IX OTHER ❑ DISTANCE TO NEARE*: SEPTIC TANK SEWER LINES „ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications J F1 Public C1 Other Ll Delta Depth of Grout Seal Type of Grout --- I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Dane ❑ Type of Pump Su' H.P. 3 State Work Done Installed new motor Well Destruction ❑ Well Diameter Sealing Material (top 50'1 J i Depth Filler Material (Below 501 _ ti TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_ Commercial Other (7 s Number of living units: Number of bedrooms Character of soil 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 FILTER BED ❑ Distance to nearest: Weld Foundation Property Line SEEPAGE PITS { I bepth-- $ize Number SUMPS Ll Distance to nearest: Well Foundation Property Line .. DISPOSAL PONDS ❑ I hereby certif it-Nthat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and reg la ions of the San Joaquin L6cal Heatth District. Home owner .r tensed agent's signature certifi )the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any rs n in such manner to beeom _. bject to orkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the f to Ing: "i certify that nth m ce oftork for which this permit is issued, 1shall employ persons subject to workman's compensation lawofThe applicant 11 1 r r ns cti omprawing on reverse side. Signed X .�'e c Tre s Date: 6 March 9 0 DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by --� Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 CK RECEIVED 13Y DATE PERMIT NO. INFO CASH +.'EH 13.24 IREV. EH 14-28 1 � ��• i