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APPLICATION FOR PERMIT d SAN JOAQL'IN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) f ' '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 illie. e is ` 1 nt V & ns��n Name Owner's Name Ogden Food .products Address Drawer J4 Stockton 95201 Phone .946 41u"36 Contractor's Name Clark Well: & E U1 License No. —371L560, Phone 462- TYPE OF WELL/PUMP WORK: NEW WELL [2 WELL REPLACEMENT DESTRUCTION U & Well A ban d onm e n t PUMP INSTALLATION [5d SYSTEM REPAIR OTHER E .� DISTANCE TO NEAREST: SEPTIC TANK .s SEWER LINES DISPOSAL FLO, PROP. LINE _+1_001 FOUNDATION AGRICULTURE WELL OTHER WELL +2 50 f PITS/SUMPS G- INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I Industria f � ' Lf Open Bottom �] Manteca Dia. of Well Excavation � 301 -, Domestic/Private Gravel Pack Tracy Dia. of Well Casing 2 6 f Public SFS []Other Delta LjIrrigationType of Casing Approx. E] Eastern Cathodic Protection Depth Specifications - 250 Geophysical Depth of Grout Seal 5Q t LJ Other Type of Grout _ C� C:k ,mom w Surface Seal Installed by e Ark Repair Work Done Type of Pump T Urb i n e H.P: Q State Work Done Well Destruction Well Diameter 1611 Sealing Material (top 50') sack mix Depth 200 Filler Material (Below 50') n C lean sand ' TYPE OF SEPTIC WORK: NEW INSTALLATION L71a.}REPAIR/ADDITION—J (No septic`tank'or:se_epa`ge,pit.permitted-i.f:pub.1_ic_sewer is' ' available within 200 feet.)__ 10' - Installation will serve: Residence Commercial Other Number of living units: + (Number of bedrooms Lot size Character of soil to a depth I,f-3-feet: 1 ' SEPTIC TANK t Water table depth Type/Mfg I; r K Capacity. NO: Compartments ' PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance-;to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total Tength/size .FILTER BED Distanceto nearest:, Well Foundation Property Line SEEPAGE PITS Depth Size Number = s - SUMPS l-1 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 compensation laws of California." Contractor's hiring or sub-contr signature Certifies the following: "I certify that in the performance of the work ford;which this permit is issued, I shal ploy er n subjec to orkman's compensation laws of California." The.appl;can u cal for s } io Co plete drawing on reverse side.- stgneds x` r' le: VP—Clark Well & E Ui Date: 2.�ay FOR DEPARTM USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: "'�c? S Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by -Da te 1 l 3b `$rS L7 Tracy 835-6385 Applicant - Return all copies to: Environ ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201' FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0.ace% ' f 1 INFO pp� j+ ' QO ' iEti -bS EH 13-24 REV. 10/821 10/82 500 5 14-26 _