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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 IPERMIT 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. f ,9906 4 Job Address • 7M E of S Jack Tone Road City Stockton Lot SizePM H.J. Heinz Co,! P. O.4. Box 57 Phone :882-42 " Owner's NameAddress -- Contractor Clark Welli Address 242 E Charter Way License No. 371564 [Phone 462-7676 , TYPE OF WELL/PUMP: NEW WELL ] WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION X1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1001+ SEWER LINES DISPOSAL. FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 144'`j"OTHER WELL PITS/,SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavation�, 10It Dia. of Well Casing 6 n �. TY3 Domestic/Private El Gravel Pack—❑`Tracy`""`" —Type of Casings" S tee l --specifications 11 Public N Other 11 Delta Depth of Grout Seal 50� Type of=Grout Cement I I Irrigation _.-Approx. Depth 1 I Eastern Surface Seal Installed by Clark Well l _ Repair Work Done ❑ Type of Pump Sub H.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material l Below 50'1 —-- TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR/ADDITION 1 1 DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 feet.i Installation will serve: Residence Commercial_ Other }} Number of living units: Number of bedrooms t 'r Character of soil to a depth of 3 feet: - Water table depth r SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal.-- Distance to nearest: Well Foundation Property Line ; LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation . Property Line SEEPAGE PITS# I I Depth I Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Cine{ DISPOSAL PONDS ❑ iS 11 hereby certify that I have prepared this applicaii,oniand that the work will be done in accordance with San J q in county ordinances, state laws,,and `rules and regulations-of the San Joaquin Local Health District" ' r 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 erson in such manner as to become subject to workman's compensation laws of Califomia.",Contractor's hiring or sub-contracting signature certifies the Ilowing: "I c "y that in theqrfoarmane the work for which this permit is issued,(.shall-employ.persons"subject to workman's compensa- tion laws of alifornia."The applic t t call f all quir itplete.' irig on reverse`.side. * v ..V Signed X TitleSec-Tres: Date: 24 May 1.988 + FOR DEPARTMENT tlSE_ONLY Application Accepted by Data 2,3 —=I— tear 0-S Pit ordgInspection byDatd!,; /y Fina! Inspection by� 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 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH13-24(REV.I/n 5) EH 14-26