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/- 3 S� APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i Ofd AVE.', STOCKTON, CA �� { Telephone (209) 466-6781 12 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made t6 the San Jbaqunlocal 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .3211 S Holt Rd City TTQ 1 t Lot Size +'1 0n a rrro re-s PM ; Owner's Nameconrad. S i I va Address Phone4 65 Contractor Clark Well Address 2024 E. Charter.-Ray License No.'371 560 ._Phone4 — TYPE OF WELL/PUMP NEW WELL )FOA WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I I Ej SEWER LINES DISPOSAL FLD. 1 PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS �• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS XX Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 2tt Dia. of Well Casing 12 ❑ Domestic/Private XN Gravel Pack d Tracy Type of Casing PVC Specifications CL 125 FI Public ❑ Other XFA Delta Depth of Grout Seal5flw Type of Grout urntenite . I I Irrigation Approx, Depth I i Eastern Surface Seal Installed by_ C _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is „ 4, }fir available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living,units:: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK - ❑ -TypelMfg Capacity No. Compartments d/ PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size n FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I' 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 agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not i 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, I shall employ persons subject to workman's compensa- tion laws of Californi ' The applican f r red irjfpecti�aps. Complete drawing on reverse side. Signed Title: VP Clark Well, INC Date: 27 Dec 1989 FOR DEPARTMENT USE ONLY Application Accepted by Date r 2 Area Pit or Grout Inspection by 4 Date �I �Z t Cf Final Inspection by �/I ��() Date _ r Additional Comments: y ('�«�f ! j"� •� J �� ❑ Stk 466-6781 ❑ Lodi 369-3621 o mail;rfeca 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 FEE INFO OUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. ♦.EH 13-21(REV.tiw5) Oro vkT0 EH 11-26 V V� 1,