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APPLICATION FOR PERMIT SAN JOAQUIN LOCAs. HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. MICKE GROVE REGIONAL PARK Job Address _ 11793 N MI CKE GROVE RD City LOOI Lot Size PM owner's NameSAN JOAQUIN COUNTY Address _ Phone 369 2205 _.._-Contractor's Name Clark Well & Equ1PLicense No. 371560 _ Y Phone 462-5597 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 _ PUMP INSTAL t SYSTEM P IR ❑ OTHER X Test Well DISTANCE TO.NEAREST: SEPTIC TANK �D SEWER LINES-+ DISPOSAL FLD. PROP. LINE +75 _.j + t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6" open hole ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private- ❑-Gravel Pack ❑ Tracy Type of Casing Specifications )XPublic y M❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' ❑ Irrigation' __-Approx. Depth ❑ Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 , Depth Filler Material (Below 501 _..... TYPE OF SEPTIC WORK: NEW INSTALLATION ❑REPAIR/ADDITION ❑ DESTRUCTION L7 (NQ septic system permitted if,public sewer is l .,..r ) f ,` "W J available within 200 feets) Installation will serve: Residence' Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' Water tabl?ds-- +' SEPTIC TANK ❑ Type/M� Capacity No. Compartr111ants PKG. TREATMENT PLT. ❑ Method of Disposal r� Distance to nearest: Well Foundation Property Line f d� LEACHING LINE 5 ❑ No. & Length of lines Total length/size FILTER BED © . Distance to nearest:°'� Well Foundation Property Line r SEEPAGE PITS ❑ t�Daptll— Size Number: ` f i SUMPS f� DristAnce to near4st: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby,certify that 1 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 shelf not F ti employ any person in such beco a subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies tie following; "•I that in mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal'forn' .' The apacan s }I o a e ire plate drawing on reverse side. Signed Title: VP—Clark well Date: Oct 29 1984 .- `FOR DEPARTMENT USE ONLY t - / Application Accepted by - I Date Area _ Pit or Grout Inspection by Date Final Inspection by 2!f Additional Comments- O Stk--466-Ml -❑ Lodi -369-3621, ❑ Manteca-823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. r + EH13-241REV.10183E EH 1426 i