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r , , r APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (.209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'Womplete in Triplicate) ' i 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. • , Pre-72 Subdidvisian Job Address 9617 E hive Oak Rd City T, 3_ Lot Size 4 aero PM same Owner's Name Tibor Boda Address Phone 3345721 - Contractor Clark Well Address 2024 E. Charter License N0.371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT{ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 75 ' PROP, LINE 4.1_e0 t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 3/411 - Dia. of Well Casing 8 Si8" IA Domestic/Private XI Gravel Pack ❑ Tracy Type of Casing Steel Specifications #10 1-1 Public F1 Other ❑ Delta Depth of Grout Seal 300 Type of Grout_9__eack.__.=__. - 'f I I Irrigation Approx, Depth I I Eastern Surface Seal Installed by itheia Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 50') __ ! TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION i I (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 X LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I 1 Depth Size _ Number SUMPS L] 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 f, rules and regulations of the San Joaquin Local Health Di"strict. 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 cern t in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa tion laws of Calif o nia.1, The applicant c Vri,. i s. Complete drawing on reverse side. Signed X Title: VP Clark Well Date: 11 Oct 89 FOR DEPARTMENT USE ONLY Application Accepted by Date '� Area _/�i� V Pit o Grout nspection by Dat Final Final Inspection by t /i�/ / I'"'Uate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy K35-&5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ; FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24(REV.1i H5) EH 14-26