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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 — ,r 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 f the San Joa uin Local Health District. lot Ow Record Job Address City Lot Size 4496 West Highway 4 Stockton - 157 Acres PM Pre-1972 j august Mazzanti 4496 West Highway 4 465 8636 Owner's Name Address Phone Clark W e i i R 371560 - 462-76'76 i Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ 4 —DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR 0�M OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 50 t _SEWER'LINES BOX DISPOSAL FLD. PROP. LINE +200' FOUNDATION AGRICULTURE WELL OTHER WELL--10-0' PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFigA qNS 1 o tt _171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excay�afion .� Dia. of Well Casing X1 Domestic/Private W Gravel Pack ❑ Tracy Type of Casing lL 1613 PVC Specifications bul❑ Public ,., ❑ Other IR Delta Depth of Grout Seal Type of Grout E' O t8 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ ;Type of Pump H.P. State Work Done Well Destruction ❑, Well Diameter Sealing Material {top 501 r Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 6 f available within 200 feet.! Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ —No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ •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. 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 following:"I certify pert mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C lifo nia." The applica t c I or 11 r r ins c s mpl drawing on reverse side. t Signed Title:V — Clark Well Data: 11 Dec 1985 FOR DEPARTMENT USE ONLY r� ' Z ��7 r Application Accepted by Date�-2 — Area � F3 Pit or Grout Inspection by 1 Date AZ��`� Final Inspection by Additional Comments: Cl Stk 466.6781 ❑ Lodi 389-3521 ❑ 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 PERMIfNO. INFO CASH FF q +EH 1324(REV.14183) '] ` y Z p - -4 1{ !b- # EH M28 J _F