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APPLICATION FOR PERMIT x t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 � + i DATE ISSUEp 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 oflthe San Joaquin Local. Health District. Job Address 9606 Lynch Road,Manteca____ Subdivision Name Owner's Nafne Bob L Ch 1 Address§606 Lynch Road,Mame ca Phone 982-4445— Contractor's Name C larK Well License No: 371560Phone 462---5-597 TYPE__OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION F-1 PUMP INSTALLATION ❑ SYSTEM REPAIR [] OTHER a Deepen Ag Well DISTANCE TO NEARE5T: SEPTIC TANK; SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL 2 OTHER WELL PITS/SUMPS ,INTENDED 315E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial [N Open Bottom ❑Manteca Dia, of Well Excavation 16" ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing } ❑ Public ❑ Other ❑ Delta Type of Casing EXIrrigation Approx. Eastern Depth � Specifications F-1CathodicProtection t Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction U Well Diameter Sealing Material (top 50') Q Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public-sewer is } available within 200 feet.) I Installation will serve. Residence _ Commercial _ Other Number of living units: I . Number of bedrooms Lot size Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type%Mfg Capacity Method. of Disposal 5 Distance to nearest: Well Foundation Property-Line. 1 LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property line SEEPAGE PITS' ❑ Depthl Size Number SUMPS U Distance to nearest: Well Foundation Property Line f j ,. DI5P05AL PONDS ❑ I - WWWWWWWWWWWWWWWW I hereby cer ' ed this application and that the work will be done in accordance with San Joaquin county ordinances, to laws, and rules an lations of the San Joaquin Local Health District. Home owner or 1 nsed agent's signature c rtifies the following: "I certify that in the performance of the work for which this permit is issued, hall not employ an erson in such manner as to become subject to workman s compensation laws of California." Contractor's hiring o b ontract1 ig ture c tifies the following: "I certify that in the performance of the work for which this permit i ss d,, l em {ler s su ct to workman's compensation laws of California." The applic ca -r uir Pe s. Complete drawing on reverse side. Signed x Title: VP-Clark Well Date:2� April 1883 OR D ARTMENT USE ONLY Application Accepted by , Area e Stk 466-6781 Additional Comments: ❑ Lodi 369-3621- Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date —A ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT,' DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO —so EH 13-24 REV. 10/82 10/82 500 14-26