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APPLICATION FOR PERMIT 14 3d SAN JOAQUIN LOCAL HEALTH DISTRICT 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. 8545 Helen Lane Stockton 131 'X 295 ' 83-84 Job Address City Lot Size PM Ron Bascou 4521 Quail Lakes Drive 957-3249 - Owner's Name Address Phone I Contractor Clark Well Address 2024 C• Charter Way License No. Phone phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ( WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES DISPOSAL FLD. 10 0 T PROP. LINE 1 0 f FOUNDATION AGRICULTURE WELL OTHER WELL 40' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation lu 5/8" Dia. of Well Ca 6/0 It ng Domestic/Private "Gravel Pack ❑ Tracy Type of Casing Steel Specifications i 1 ❑ Public ❑ Other ElDelta Depth of Grout Seal Type of Grout 9 Beek [ill ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Clark Repair Work Done 0 Type of Pump SUh H.P. 3 State Work Done_Install Pump Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material IBelow 501 JI TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is U� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil tD 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: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. Home owner or licensed ag certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r; employ any person it such er as to a subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature) certifies the folio in : "I ce y ,a i rmance of the work for which this permit is issued, I shall employ persons subject to workman's campers tion laws of C r Ia."" The applica II r al I d i n . Complete drawing on reverse side. VP— Clark Well 14 April 1986` Signed X Title: Date: s FOR DEPARTMENT USE ONLY ! v t Application Accepted by Date Area Pit or Grout Inspection Date Final Inspection by Date 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 N p AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24IREV.F/851 �_` EH 14-28 [S