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y APPLICATION FOR PERMIT / / /r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA (, S A Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 3S F le 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 Lmoadae� in comp,pli�ance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Wellealsi e`t# 1 Santos Ranch Unit # 5 NW corner of Lot 29, couTie�t_h-.-, Tracy 401x601 ,,,s-31-9 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 they 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 a me subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certi in the nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican at II f all re lie pec >' pie drawing oneverse id . SignedX Title: Date: 917184 /84 ir FOR DEPARTMENT USE ONLY Application Accepted by J Date Area Pit or Grout Inspection by r �� Dat�eFinal Ins ton by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3W3621 ❑ Manteca 823-7104 Cl ❑ Tracy 8354M5 Applicant - Return all copies to: Environmental Health Permit/Servicers 1601 E. Hazelton Ave., P.O. Box 2()09, Stk., CA 95201 t EH 1324 IREV. 101M EH 14-25 FEE AMOUNT DUE W. Dave Olmstead PO 'Box 134 Tracy 835-7284 owner's Name Address Phone Clark Well h EgUip 371560 Phone 462-5597 Contractor's Name License No. TYPE OF WELL/PUMP: NEW WELL 1* WELL REPLACEMENT ❑ DESTRUCTION ❑ CASH PUMP INSTALLA1TLpN.t[* SYSTEM REPAIR ❑ OTHER ❑ 301 ,,SS UU DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 16" ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing S to ❑ Domestic/Private X Gravel Pack 29 Tracy Type of Cesing ,• Specifications r 9 $I Public ❑ Other ❑ Delta Depth of Grout Seal 10 u Type of Grout sack Clark ❑Irrigation ---Approx. D,ep th ❑ Eastern Surface Seal Installed by 60 install Repair Work Done ❑ Type of Pump l urbine H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 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 ❑ 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 ❑ e 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 they 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 a me subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certi in the nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican at II f all re lie pec >' pie drawing oneverse id . SignedX Title: Date: 917184 /84 ir FOR DEPARTMENT USE ONLY Application Accepted by J Date Area Pit or Grout Inspection by r �� Dat�eFinal Ins ton by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3W3621 ❑ Manteca 823-7104 Cl ❑ Tracy 8354M5 Applicant - Return all copies to: Environmental Health Permit/Servicers 1601 E. Hazelton Ave., P.O. Box 2()09, Stk., CA 95201 t EH 1324 IREV. 101M EH 14-25 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT `NO. INFO CASH O"00