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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT 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. Job Address 705 East Lodi Ave City LOCH Lot size 240x1 67 — pm Cityr8fL o Vieth Engi2 %e eSt Pine Stree 333 6706 Owner's Name are Phone Contractor's Name Clark Well License No. 371560 Phone46 2—7 6 7 6 TYPE OF WELL/PUMP: NEW WE _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK nnnl' SEWER LINES I�B(p DISPOSAL FLD. PROP. LINE 1 ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 321 Dia. of Well Casing n ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing z Specifications .2 5 0 k, Public ❑ Other 11Delta Depth of Grout Seal Type of Grout 9 sack Q ❑ Irrigation ---Approx. Depth �Eastoq Surface Seal Installed by Repair Work Done ❑ Type of Pump c "t11 H.P. State Work [akark (� Well Destruction ❑ Well Diameter Sealing Material (top 501 11 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 ❑ 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 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 foil ert' 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 if la." r The applica s ca f all u' inspections. Complete drawing on reverse side. Signed Title: VP—Cl ark Well Date: 1 Ma);, 1988 FOR EPAfLTMENT USE ONLY Application Accepted by JDate —,-4—'CJ Area Pit or Grout Inspection byData Final Inspection by Date Additional Comments: K aA ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca'. 823-7104 ❑ Tracy"835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO.' y G +EH 13-24(REV.10183) ` `Y EH 14-28 r 4 - -