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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Joaquip Local Health District. K ( ree"*pijj - k - Job Address 12123 East Norman lJ f city Stockton Lot Size 5 acres PM Owner's Name Brian Kent Address 86 North Patrick 948-3094 Phone Contractor's NAlark Well & EquipmeT>Lcense No. 371 560 Phone 462-7675 TYPE OF WELL/PUMP: NEW WELLXk WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION XX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 10 0 111 SEWER LINES DISPOSAL FLD. PROP. LINE gL FOUNDATION 9 F AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL - PROBLEM AREACONSTRUCTION SPECIFICATIONS C1Industrial ElOpen Bottom ElManteca Dia. of Well Excavation 10 Dia. of Well Casin96 5/8" Xl(R Domestic/Private XRI Gravel Pack ❑ Tracy Type of Casing Specifications . 109 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 9 sack ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Sub H.P. 3 Np State Work Done install Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ? i Number of living units: . ' Number of bedrooms ' .- . ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑, Type/Mfg s.-t , Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 signature certifies the following: "I 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 followin t in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif i The applicant I or II in ctions. Complete drawing on reverse side. Signed Title: VP Clark Well Date: 23 May 1988 FOR DEPARTMENT USE ONLY � 45 4-10 �� Application Accepted by /,�}, / Date y Area Pit or Grout Inspection b '-' V/ Date FI I Inspection by / Date Additional Comments: l a + ❑ Stk 466-6781 ❑ Lodi 1 ❑ Manteca 823-7104 ' ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INr/FEE �� J INFO AMOUNT DUE AMOUNT REMITTED CCAS H RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.10/8,9) EH 1428