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APPLICATION FOR PERMIT jA� /� j'1�l� SAN JOAOUIN LOCAL HEALTH DISTRICT 7 7 1601 E. HAZEL T ON AVE., STOCKTON, CA E Telephone 4(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. ' Job Address 6185 Garnica Court cityStkn Lotsize1 1 /2 Acre PM i Mr. Joe Ellis Address 390 MontereyPhone 943-7585 Owner`s Name Contractor's Name Clark Well License No. 371 560 Phone 462-7676 '.° TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 5d SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK 1'00 SEWER,LINES DISPOSAL FLD. PROP. LINE 10_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 5 8" }� Domestic/Private ER Gravel Pack ❑ Tracy Type of Casing Stee 1 Specifications#12 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50 ' Type of Grout 9 sack ❑ Irrigation _�4pprox. Depth ❑ Eastern Surface Seal Installed by Clark, Repair Work Done ElType of Pump Sub H.P. 3 State Work Done instal I f Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 67 Installation will serve: Residence— Commercial_ Other i { Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth OD 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 t FILTER BED ❑ Distance to nearest: Well Foundation Property Line - 7 SEEPAGE PITS ElDepth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 1 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. r 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."Contractors 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 C 'rforni The applica st I o re it i s ct ns. Complete drawing on reverse side. to Signed Title: ' Date: _5�— i n 1928 `s FOR DEPARTMENT USE ONLY I Application Accepted by Date -7/�- Area Date aklirFinal Inspection by Date Pit or��spection by IV - Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 k FEE I AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE_. PERMIT"NO. INFO {,�/y� fv — � + EH 1324{REV.107831 /C./ �`V �.. �t�' •ti S _ e /][ � , EH 14-26 �1.V (d