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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT :1601 E. HAZELTON AVE., STOCKTON, CA f 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 Sari Joaquin Local Health District. 11 Job Address 3211 S. Holt Rd City Holt Lot Size +1 Q0 acres PM Owner's Name Conrad Silva Address Same Phone 465 1834 Contractor Clark Well Address 2024 E. Charter Wa License No.371560 Phone 4-6 — TYPE OF WELL/PUMP: NEW WELLtk WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 DO! SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL 97_' PITS/SUMPS INTENDED USE TYPE OF WELL . PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 14 r' Dia. of Well Casing 8 " MXtomestic/Private JDXGravel Pack ❑ Tracy Type of Casing PVC Specifications CL 1 25 [1 Public n Other Xkl pelta Depth of Grout Seal Type of Grout Beritenit—e l 1 Irrigation — Approx. Depth I I Eastern Surface Seal Installed by A- Repair Work Done ❑ Type of Pump H.P. State Work Done T Nl�zal Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 Vi TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION 1 1 (No septic system permitted if public sewer is available within 200 feet.1 N Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion lawsJCaThe appliR. �o re ins ctions. Complete drawing on reverse side. Signed X Title: VP Clark Well Date: 27 Dec 1989- (� �F DEPARTMENT USE ONLY Application Accepted by Date Z v Area S Pit or Grout Inspection by Date /�� % Final Inspection by Date Additional Comments: LJ5tk 466-6781 Lodi 369-3621 ❑ Manteca 623 7 ❑ racy 835 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. INFO CASH + W 13241REV.I/11 51 70, 001