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3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 ; PERMIT EXPIRES TYEAR 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 4L}1_Q_ Hnl t Rt3 City Halt Lot Size +A0___aCre9i_ PM E- 1 Owner's Name 12 c–) ��.a�.S 11ya Address 3 2 1 1 S_ Holt 1 t, R d Phone t Contractor Clark Well Address 2024 Z.. Charter WayLicense No.31560 Phone4,C,2— 6-76 TYPE OF WELL/PUMP: NEW WELLgk WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 10 0 t SEWER LINES DISPOSAL FLD. PROP. LINE 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 ')" Dia. of Well Casing u kk Domestic/Private ,ravel Pack ❑ Tracy Type of CasincPV(` Specifications C1125 f"1 Public F] Other X[� Delta Depth of Grout Seal 3 0 r Type of Grout CC �� I I Irrigation --Approx. Depth [ I Eastern Surface Seal Installed by owner � Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 C2 Irz,J1 Lr Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) 1 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 ❑ 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 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size __ Number SUMPS Cl 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 Di§trict. 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 followi c ify 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 C o ia." The applic t 1 all r uire spections. Complete drawing on reverse side. Signed r. Title: VP Clark Well Date: 27 D4=C 1989 DEPARTMENT USE ONLY 1 Application Accepted by ��__ -� I—?Date --�� Area ` Pit or Grout Inspection by DataFinal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 7 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '• z I INFO OUNT D`U'ES'] AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-241REV.1i 85r O . EH 14-26 1