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t APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 3-- y Telephone (209) 466-6781 PERMIT UPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED O Z +/ � 3,4074A)". J w mplete in Triplicate) ` .: € - C3 (CSB _CLT Application is hereby made to th n Joaquin Local Health District for a permit to construct and/or install the work herein describ"ed. This application is de n compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump _ and the Rules and Regulations the San Joaquin Local Health District. N k Job AddressI76V-Fat.te . sonR.C,(W)&Pattersias'obdf dsidrit)me Seo-nkton: Owner's NameGeor e Patterson Ca is svdress P.i HBc tk '_ X5208_ Phon�(��gQ 946-121C Contractor's Name Clark . Well License No. 3El56Q � Phone 462--5597 TYPE OF WELL/PUMP WORK: NEW WELL ] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER r ' DISTANCE TO NEAREST: SEPTIC TANK �. 1,50 t SEWER LINES DISPOSAL FLO. PROP. LINE - FOUNDATION AGRICULTURE WELL 5[jt OTHER WELL PITS/ MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom � Manteca Dia. of Well Excavation 10 -5/8 Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing 6 5/8" �]Public Other iD Delia Type of CasingGI A60 PVC Lj Irrigation Approx. .Eastern Specificationx F-1Cathodic Protection Depth t r Depth of Grout Seal � jiQ Geophysical Type of Grout 9. sack mix ' Other Surface Seal Installed by Clark.. k Repair Work Done ❑ Type of Pump SUhr H.P. I State Work Done 11TT.Stal-I Pum Well Destruction U Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') ^` TYPE OF SEPTIC WORK: NEW INSTALLATION+ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is � available within 200 feet.) , m Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth if 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 7 DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size t FILTER SED ❑ Distancel.to nearest: Well Foundation Property Line j SEEPAGE PITS ❑ Depth Size Number t SUMPS L 1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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. Homy owner or licensed age a certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalWo in such manner as to become subject to workman compensation laws of California." Contractor's hiring orse certifies the following: "I certify that in the performance of the work far which this permit is issued, Iubie to workman's compensation laws of California." The appicacal t' s Complete drawing on reverse side. Signed x Title: VP—Clark Well Date:74 n,.,-_ 8.1 F R R T.J�SE ONLY r Application Accepted by �' `"�Area"�D� '�' ~` tk Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date d-�� 3 Manteca $23-7104 Final Inspection by Date •� f L Tracy X835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.', CA 95201 p I .l FEE BASE AMOUNT DUES AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 1-7 Fir EH 13-24 REV. 10182 10/82 500