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APPLICATION FOR PERMIT _ r' SAN JOAQUIN LOCAL HEALTH DISTRICT — ' 1601 E. HAZEL T ON AVE_ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) GJ r 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. LXXA` 0 Pre-72 cr` s Job Address 0 City 5�' Lot Size 10 APM �r David Grillo address 3535 N. Persh' e 62-2282 Owner's Name I� l contractor Clark Well Address 2024 East Charter License No371560 Phone462-76' 6 l� TYPE OF WELL/PUMP: �I: NEW WELOU WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK +100' SEWER LINES — DISPOSAL FLD. PROP. LINE++__L0_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1.0r' Dia. of Well Casing ZSrt gl Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing�Steel Specifications #12 r ('l Public M Other ❑ Delta Depth of Grout Seal 5n Type of Grout 0__rqr_� I I Irrigation -'11.-Approx. Depth I I Eastern Surface Seal Installed by Q� + -Repair Work Done ❑ Type of Pump S1th H.P. '3 State Work Done Tr st2l l Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 a `. TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sower-is,^ II available within 200 feet.) Installa -I serve: Residence_ 'Commercial_ Other 11' a Number of living uni Number of bedrooms Character of soil to a depth of 3 Water-table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Welt Fou n Property Line LEACHING LINE ❑ No- & Length of lines Total lengt FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line i SEEPAGE PITS I I f)epth Size Number (1Z)SUMPS 0 Distance to nearest: Well 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. i I Home owner or licensed agents 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 insuch manner to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following; "I certify t t in the rfo ance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif nia." i The applican c If irec m to dra ing on reverse side. A 1? VP-Clark Well 2 Sept 1987 Signed X - ills: Date: FO DEPARTMENT USE ONLY 77 r i Application Accepted b .I Date / a Area /01 Pit or rout Ins do Date F- spection by Date L I� �Jo ` /' rM 1 i Ad i conal Comn'1�c1t �r 1��t/ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applic Return all copies to: Environm ntal Health Permit/Servic s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201; IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED Y DATE PERMIT iJO. 1 + EH 13-24(REV.i i H 5) ` EH 14-26 ��