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I! APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCK-TON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED �.. 031.;"� 31,TL �j qr . . . • , (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 Joe bin County Ordinance.No.549 for sewage;or-No.,18621or well/pump and the Rules and Regulations of the San Joaquin i Local Health District.t{, 4� _ , ri ,. -. .. {kneil�►n as Artesia Door) ' 6800 Etst�}Fai>" hild ' !` " } Stocktol ? 3/4 acre Job Address - -City Lot Size PM - - gest-'Cost -:Dear— _6800=E.- Fairchild -- 939--4825 Owner's Name Address _ Phone Contractor's Name Clark Well License No. 371560 Phone 462-5597 TYPE OF WELL/PUMP: I` NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ *- .1 a PUMP I•INSTALLATION X" — - •--- SYSTEM REPAIR ❑ }�WR ❑ 251 Q DISTANCE TO NEAREST: SEPTIC TANK 4-1[101 SEWER LINES DISPOSAL FLD._ 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 tt Dia. of Well Cal'ng 6 5/6 tt D St8131" 12 ❑ Domestic/Private � Gravel Pack El Tracy Type of Casing Specifications �i:- w 4 6 Public ❑ OA r- ❑ Delta Depth of Grout Seal 5 0 Type of Grout- 9 sack ❑ irrigation iprox. Depth ❑ Eastern Surface Seal Installed by Clark .4 Repair Work Done ❑ Type of Pump Sub H.P. State Work Done Install Well Destruction,: ❑ Well piameter Sealing Material (top 501 Depthl Filler Material (Below 501 , TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer-is , r available within 200 feet.) .- Installation will serve: .Residence'`a Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK j ❑ Type/Mfg Capacity 'No. Compartments ' PKG. TREATMENT PLT. ❑ "' Method of Disposal " Distance to nearest: Well Foundation'" Property Line LEACHING LINE. ❑ No!'& Length of lines Total length/size ,l`\ ��. 'FILTER BED =❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS s ❑ Depth Size Number -'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. ;s . 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 t int or ante the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal r The applica al ! it in c mpl to drawing on reverse side. 1. 1 Clark Well–VP 25Nov 1985 Signed X i! _ Title: Date: = E a I FOR DEPARTMENT USE ONLY^ Application cepted by i Date Area ! Pit or rout I pection by �` Date IL Z ' Final Inspection b Datt - i - ? - - - Additional Comments: ❑ Stk 466.6781 0 Lodi- 369-3621 ❑ Manteca 623-7104 _ ❑ Tracy 835-6385 t Applicant- Return allL copies to: Environmental Health Permit/Services_1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EKAMOUNT DUE AMOUNT REMITTED CRECEIVED BY DATE PERMIT"N0. INFO CASH s- Yy + EH 1324[REV.10!831 ; I j �__ " �j 2 S-r.7 8S EH 14-28 I i O 7