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j - I APPLICATION FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -top" (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. 1851 for well/pump and the Rules and Regulations of the San Joaquin } Local Health District. Job Address 13373 EaSt' Hwy". 'l20 City Manteca Lot Size 1 Acre PM Owner's Name Richard Gress Address 13'19 Bryant Court Phone 823-7022 Clark Well 2024 E. Charter Way 3'71560 462-7676 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION 93C SYSTEM REPAIR ❑ OTHER ❑ v V DISTANCE TO NEAREST:-SEPTIC TANK _ +I flfl t SEWER LINES DISPOSAL FLO.- PROP. LINE+751 \ t FOUNDATIQN AGRICULTURE WELL OTHER WALL PITS/SUMPS V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF C TI t 5/811 El Industrial ❑ Open Bottom I*Manteca Dia. of Well Excavation Dia. of Well Casigg lZ Domestic/Private 9 Gravel Pack ❑ Tracy Type of Casing Specifications 9L sack ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout [I Irrigation ---Approx. Depth El Eastern Surface Seal Installed by Clark Repair Work Done ❑ Type of Punip Sub H.P. 2 State Work Do a Install Well Destruction ❑ Well DiameterSealing Material ftop 50'1 p + Depth 1 r� Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) i Installation e: Residence _ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fee . Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I _.,Methpd of Disposal } Distance to nearest: Well ion Property Line I I r' LEACHING LINE ❑ No. $ Length of lines �.°.� i 9 Total size FILTER BED ❑ Distance to nearest: Well Foundation Property SEEPAGE PITS •¢ ❑ 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, an 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 i employ any person i r as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature I certifies the fol) i certify th t' t performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of or a The applica t t c for II quir in ctions. Complete drawing on reverse side.. Signed Title: VP Clark Well Date: 15 July 1967 E E RTM T USE ONLY Application Accepted by. Date Area Pit Grou Inspection by Date O Final Inspection by y� � Date,?—,;L a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 '0 Tracy 835-6385 (; Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 7 CK*1+ .f y INFO, AMOUNT DUE AMOUNT REMITTED; CASH RECEIVED BY DATE PERMiT`NO. , i +£H 13-24(REV.i/R 5) / /`^� '•,.,,, 'y . ,.0 EH 14-28 /��/