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LL APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT —,. 1601 E. HAZEL I 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„D3StcVb Gave Regional Park Lo T OIG 22 cdAD Job Address 11793 N. Micke Grave City Lodi Lot Size PM Owner's Name S'J• County Address Phone 369-2205 Contractor's Name Clark Well & EgUiRicense No. 371560 Phone 462-5597 TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT ❑ DESTRUCTION ❑ ---.-..,—PUMP INSTALL�LT �1t❑ " SYSTEM REPAIR ❑ OTHER ❑ #CJS f DISTANCE TO NEAREST: SEPTIC TANK U SEWER LINES DISPOSAL FLD. PROP. LINE r, FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ; l i TYPE OF,WELL: 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation /Dia. Of Well Casing 2611 Conduct ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing SteelSpecifications, 16"0250 ❑ Public El Other ❑ Delta Depth of Grout Seal ?5 t Type of Grout 0 9 sac h ❑ Irrigation �#Approx. Depth ElEastern "Surface.Seal Installed by 314 k _J Repair Work Done ❑ Type of Pump H.P. State Work Done 9 Well Destruction ❑ Well Diameter Sealing Material (top 50') W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted.if public sewer is Z available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms s !, J Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: ;r. Well Foundation - ""Property Line p. LEACHING LINE ❑ No. & Length of lines Total length/size 3 FILTER BED ❑ Distance td'nearest: "Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line } DISPOSAL PONDS ❑ 711 ` 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 ofthe ocal Health District. ✓ --_ Home owner or licensed a nt's signature rtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in suchanner as to b ome subject to workman's compensation!laws of California."Contractors hiring or sub-contracting signature certifies the following:"I ce tin th ormance of the work for which this-perMitis issued,1 shall employ persons subject to workman's compensa- tion laws of Cali orni ." i ' f �- The applican s all f II uir d nspe io o t drawing on reverse side,— Signed X Title: VP—Clark Date: ' 17 May 1965 FOR DEPARTM T USE ONLY Application Accepted by Date `Arreaa 61 J Pit or Grout Inspection by - Date 17S�S final Inspection by w Date Additional Comments: _ ❑ Stk 466-6781 ❑Lodi 369-36221 ❑ Manteca 823-7104 ❑ Tracy 4 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 FEE}NFO /AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. { EH 1344 MEV.10/831 j/ Q/,�� - ��f� a S Cys