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I APPLICATION.FOR_.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—I ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ' �= alocal Health District for a permit to construct and/or install the work herein desc Application is hereby ribed.This application is made to the San Joaquin made compliance with San Jaaquin,CountyOrd-+nance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin l Local Health District.- .Orrr.. tStkn Lot Size 6 Acres PM x� 11600 {pari' 0se }; city Job Address 463-1857 2 807 E. Miner Phone4 Owner's Name JOSe ' Yanez Address i ' ' Clark Well . Address Y2024 Cash Charier License No 371560 Phone 462-767G Contractor TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 751 DISTANCE TO NEAREST: SEPTIC TANK 120 SEWER LINES DISPOSAL FLD. PROP. LINE Q f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 811 Dia. of Well Casing 5 1t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation , 2 Type of Casing S t e e l Specifications X1 Domestic/Private x] Gravel Pack ❑ Tracy yp 5 0 f Type of Grout 9 sack ❑ Public [I Other LI Delta Depth of Grout Seal Clark Li Irrigation ---Approx. Depth F1 Eastern Surface Seal Installed by install Repair Work Done ❑ Type of Pump _ -- H•P• 8 State•Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REP ❑ DESTRUCTION ❑ aNailableiWithin00 feet.) if public sewer is Installation will serve: Residence Commercial_ -tither Number of living units: Number of bedrooms Water table depth I>' Character of soil to a depth of 8 feet: No. Compartments SEPTIC TANK 71Type/Mfg Capacity ` Method of Disposal PKG.TREATMENT PLT. ❑ r Property Line t �` ry k`F3 Distance to nearest: Well Foundation tri 1 . LEACHING LINE ❑ No. &Length of lines Totallength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line—; ' Number t' SEEPAGE PITS N-id Depth Size SUMPS ❑ Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS ❑ 1 . 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 sig nature-certifies the following: "1 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 personfollowiin ' ce i at in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion lawsof lifor i " The applic I f II r d ' spections. Complete drawing on reverse side. Signed Title: . VP— lark Well _ Date: 30 3une 19137 FOR DEPARTMENT USE ONLY Lt-Date Area Application Accepted by6' y Date�. ' Final Inspection by DateF Pit or Grout Inspection by Additional Comments: T ' ❑ Stk 466-6781 0'Lodi -x369-3621 1-] 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 CK RECEIVED BY DATE PERMIT'N0. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO + EH 13-24(REV.1/85) 4J " _ - EH 1428