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.� APPLICATION FOR PERMIT a C SAN JOAQUIN LOCAL HEALTH DISTRICT `d 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t AY 9 1989 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED ENViR0iaViE1`SiAI_ HEAL7M (Complete in Triplicate) pERMI-f 1 SERVICES 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 22490 E Highway 4 ityStockton Lot Size PM Owner's Name Chiappe Farms Address 5419 S Stanley Road Phone 465-4828 Contractor Address Clark Well 20241E Charter Way License No. 371560 Phone 462--7676 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION -9 P SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINES DISPOSAL FI_D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation Dia. of Well Casing L*Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ., -C1-Public.__,.._......,,,.f l Other Cl Delta Depth of Grout Seal Type of.Grout Y _ i I Irrigation Approx, Depth I I Eastern "Su`rfa`ce SnI-ln1ta[led-by— Repair by —Repair Work Done ❑ Type of Pump Sub H.P. State Work DoneJT Installed Well Destruction ❑ Well Diameter 1-o Sealing Material Stop 501 Depth = --.1 Filler.Mater al (Below 50'),_ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l.1 DESTRUCTION l I (No septic system permitted if public sewer is r" available within 200 feet.) Installation will serve: Residences Commercial wa Other. t —j—i,-.. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg k` � _Capacity 1 No. Compartments PKG. TREATMENT PLT. ❑ 4 ^f t .R Method of Disposal Distance to nearest: Well Foundation Property Line t I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:-R Well---------•-••Foundation_2 Property Line SEEPAGE PITS I I Depth Size Number , SUMPS Ll 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 rulesand re Mations of the San Joaquin Local Health Di?;trict. Home own r licensed nt'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 son in su h nner as to b e subje to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certies the o owing: "!cert)y t tin ormanc the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion'_aws of lifornia." The applic' nt b it in t' plate drawing on reverse side. ' 5/5/ 9 � Signed X Title: SGC-Tre S Date: � _ f �1�, FOR DEPARTMENT USE ONLY 1 Application Accepted by Date Area ] Pit or Grout Inspection by Date Final inspection by zJ'AyX12 Date- , Additional Comments: ❑ Stk 466-6781 •- C7 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ..EH 13-24 1 REV.1/8 r � �J /1 _ -169q EH 14-28 I