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1 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 10702 N Lower Sacramento Rd city Stockton Lot Size PM owner's Name Does Recreation Address 1.0702 N Lower Sacramento Phone 477-861.3 Contractor Clark .Well, Inc. Address 2024 E Charter WayUicense No. 371560 Phone46z— 6 6 TYPE OF WELL/PUMP:1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR IX OTHER ❑ -,_.DISTANCE TO.NEARE*: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications i M Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _.Appr ox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Sub H.P. 3 State Work Done Installed new motor Well Destruction ❑ Well Diameter! Sealing Material (top 501 f Depth Filler Material (Below 501 r, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ) DESTRUCTION l I INo septic system permitted if public sewer available within 200 feet.) Installation will serve: Residence— Commercial_ Other V Number of living units: Number of bedrooms N 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 I I bepth-' $ize Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS , ❑ I hereby cortif 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 rag la ions-of the San Joaquin Local Health District. Home owner or tensed agent's signature certifi the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any rs n in such manner to becom s bject to orkman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the f to ing: "I certify that nth m ce oft work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C ia." IZ The applicant II 1 r ns cti . ompl a drawing on reverse side. signed x _ Sec--Tres Date: 6_ March 90 DEPARTMENT USE ONLY / Application Accepted by Date Area C� Pit or Grout Inspection by Data Final Inspection by I^^ � Date 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 EE IN O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE � PERMIT*NO. r EH13-24(REV.I i n 5l / Ne, EH 14-26 1 d C+SCJ