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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / p 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � 'l! ✓�l� Telephone (209) 466-6781 DATE ISSUED 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 District. Job Address 1 MilMilp E CQpPErCp0o1is&Mi1-tfubdi&sit- f)p ie Owner's Name; Address &RhoneGg5al Contractor's Name G�aTk Well 8,��License No. Phone ��„�'347 T- TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIONS f UJ PUMP INSTALLATION SYSTEM REPAIR OTHER [J- DISTANCE WL/ 1 DISTANCE TO NEAREST; SEPTIC TANK Iri SSE ALINES DISPOSAL FLO. ROP. LINE . t FOUNDATION AGRICULTURE WELL OTHER WELL+Zaa!_jg_aPdTSWJ3. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G- 1-1 Industrial U Open Bottom Manteca Dia. of Well Excavation 6 Van U Domestic/Private ® Gravel Pack Tracy Dia. of Well Casing 63 5/8 It Ll Public f—[ 0ther Delta Type of Casing # ,Z.z Steel V Irrigation Approx. Eastern Depth Specifications F-1CathodicProtection p Depth of Grout Sealam ei L7 Geophysical -- Type of Grout Other r-001ing water 4gpiT/not for drinkin%urface Seal Installed by Repair Work Done [] Type of Pump SU S: H.P. 3 State Work Done in-qta]l Pump Z Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') Y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of living units: 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 SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size e FILTER BED ❑ Distance to nearest: Well Foundation Property Line + SEEPAGE PITS ❑ Depth Size Number Ef SUMPS El Distance to nearest: Well Foundation Property Line O DISPOSAL PONDS �i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count 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 shall not em to any person . uch manner as to become subject to workmans compensation laws of California." Contractor's hiring or sub- ratting gnature c tifies the following: "I certify that in the performance of the work for which this permit i i ued I al a to r ns su ct to workman's compensation laws of California." The applic t r 11 r 1 s ec o S. Complete drawing on reverse side. Signed X Title: VP Clark Well Date: {� F PARTMENT USE ONLY Appl lation Accepted by ` ea b a 5tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date L_J Manteca 823-7104 Final Inspection by Date —7_Q— y Tracy 835-6385 Applicant - Return all &1, i to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., ICA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO o-1 223 13- 1I �0 EH 13-24 REV. 10/82 10/82 500 14-26