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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Joaquin Local Health District. i Job Address 6776 E. Foppiano City Stkn Lot Size 4f] arraG PM Owner's Name SJ Solari Address 87661N.""Helen Phone 931 —1696 Contractor Clark Well Address 2024 East Charter License No. 377 560 'Phone 462-7676 1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L�kX SYSTEM REPAIR ❑ OTHEP ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL 30 _ PROP. LINE 50 , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation 20rr Dia. of Well Casing 1 4n ❑ Domestic/Private. Gravel Pack ❑ Tracy Type of Casing St*P_P-1 Specifications . 188 f'l Public' F Other F Delta Depth of Grout Seal NA Type of Grout _ XXrrigation _Approx. Depth 11 Eastern Surface Seal Installed by zai rte_ Repair Work Done ❑ Type of Pump Stlh H.P. in State Work Done_i Elstall Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC.WORK:",NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is .i>L ; : Ca.i;,..i ra r. available within 200 feet Installation will serve: Residence_ Commercial__ Other Number of living units: � H W4 'Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK` n' r. '❑ ' TypelMfg ` =`' t `� Capacity r No. Compartments Fi 1, 'c3 PKG. TREATMENT PLT. ❑ '` 5 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 I 1 Depth Size Number SUMPS Ll 'Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS ❑ a 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 cern that in the rformance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Calif rnia " The applican all II r qu'r ins c s. C ete drawing on reverse side. signed x Title: VP-Clark Well, InC. Date:1 1 April 89 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 0 � Pit or Grout Inspecti Data Final Inspection by LJt Date Additional Comments: LJ ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 S Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 14-2e ! '