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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. Lot of Record Job Address 5196 E. WoOdbrid e Rd City Ac-a� mom_ Lot Size 17 fir-g&_ PM Owner's NarnJimmy Namba Address same Phone 36$ Clark Well 2024 E. Charter 371560 462-7676 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL R9X WELL REPLACEMENT XX DESTRUCTION PUMP INSTALLATION PSX SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK 50 SEWER LINES DISPOSAL FLD. PROP, LINE ±-1-5 0 ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 120 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial LJOpen Bottom 0 Manteca Dia. of Well Excavation I Dia. of Well Casing 6 5 g" )D Oomestic/Private �Gravel Pack El Tracy Type of Casing Stee Specifications #10 FI Public ❑ Other ❑ Delta Depth of Grout Seal S f3 ' Type of Grout 9 sack . t I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Clark _ Repair Work Done ❑ Type of Pump Sub H,P. 2 State Work Done _ i nqt-,a 1 1 Well Destruction El Well Well Diameter Sealing Material (top 50') 9 Sack IT IT • Depth NA Filler Material (Below 50'? TYPE OF SEPTIC WORK: NEW INSTALLATION i I RFFIAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.I 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS D 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the followin : "I in th rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca The app lica call II q d s cti s. Complete drawing on reverse side. SigneTitle: VP Clark Well Date:. 7 Nov 8 d FOR DEPARTMENT USE ONLY Application Accepted by _ Date 7/9 V Area Pit or Grout Inspection by Date final Inspection by ___ _ Date Additional Comments: ❑ Stk 466-6781 ❑ 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 CASH RECEIVED BY DATE PERMIT'NO. INFO +-EH 1,3241REV.1/851 / EH 14-26 Milk r