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' APPLICATION FOR PERMIT s � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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. Pre-x,972 Joh Address-383 East Hall Street �itStocktor Lot s204XI04 4ot of Recor T ize Owner's Name Eddie Gomez r Address 1.1.6 E. Clay St Phone 948-4065 Contractor's Name Clark Well 6 License No. 371 560 Phone 462-7676 . �I TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONXX SYSTEM REPAIR ❑ OTHER ❑' DISTANCE TO NEAREST: SEPTIC TANK t OO t SEWER LINES 'DISPOSAL FLD. PROP. LINE 10 FOUNDATION AGRICULTURE WELL OTHER WELL-7_'L— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, /811 . ❑ Industrial ❑ Open Bottom` ❑ Manteca Dia. of Well Excavation 5 Dia. of Well Ca$it1�26 8 ?q Domestic/Private � Gravel Pack! C3 Tracy Type of Casing SteelSpecifications ## ❑ Public ❑ Other_„ 3 ❑ Delta Depth of,Grout Seat— C Type of Grout 9 Sack ❑ Irrigation ---Approx. Depth ❑ Eastern Su a/�e Seal Installed by Clark Repair Work Done ❑ Type of Pump13 Sub H.P. 1 1/ 2 State Work Done install Well Destruction ❑ Well Diameter€ Seating Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_r Commercial— Other Number of living units: Number of bedrooms [ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments j PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lihe SEEPAGE PITS ❑ Depth Size Number _ SUMPS ❑ Distance tolnearest: Well Foundation Property Line DISPOSAL PONDS D I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the followi ify that in the performance of the work for whicK his permit is issued,I shall employ persons,subject to workman's compensa- tion laws of C 'f The applica I f ar ' n ction . Complete drawing on reverse side. Signed Title: V P-C 7.a r'k We 17 Dat$: 1.9 Aug 1.98 7 } O=PAR ENT USE'ONLY•, j Application Accepted by —' Dine Area ' Pit or Grout Inspection by s- Date Fanat ons ettion by;� �� Data Additional Comments: { 5 rt ❑ Stk 466-6781 ❑ L6di 369-3621 ❑ Manteca 823-7104 O Tracy .835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24/REV.101831 o,5rr- ` EH 1428 G-iJ