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if APPL I CATIONJOR 15E-RM17.\ " ' -\y [j SA� J6AQ'U 1 N-I 4EQTH -DMiRICT !?3--:-6 Z-E L VL1 STOCKTON, PERMIT N 0. r .71,601 E4HA` hN A I T!_I.ep6np (204) 4606781 i ' .. DATE ISSUED JPERMIT-EXPIRES11 YEAR FROM DATE, ISSUED .7,Aomplete in Triplicate), Application is hereby wade to the San Joaquin L Cal Health District for a permit to construct and/or install the work herein described. This application is with San made in complia ce wi a 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 9368 Oakwilde . .. I Subdivision Name Mi9rada Ownerls'Name Dr. Stephen Block ( Address same Phone Contractor's Name Clark Well & .Equl License No. .371560 .Phone 462-5597 TYPE OF WELL/PUMP WORK: NE! WELL QWELL REPL%-EMENT DESTRUCTION PUMP INS ALLATION SYSTEM REPAIR 01 T DESTRUCT} E R f DISTANCE TO NEAREST: SEPTIC TANK- $E W ER LINES DISOSAL FI PRO I y. f 'ri TIS 6UNDATION AGRICULTURE WELL OTHIER-WEL17 6 0 f INTENDED USE TYPE I OF WELL PROBLEM AREA CONSTRUCTION!SPEC I FlIkAT.I.O-1611 B Di, f'WLE.cavAion 1 1 2 Rill Industrial ❑ Open Bott Manteca Domestic/Private K3Gravel Pajk-JALJ TracL_ of Well Casing Public Fj Other Delta vr% Type of Casing # 1 2 -5 t e e 1 Irrigation Approx. ra' F-1 Cathodic Protection Depth Specifications -�]L Geophysical Depth of Grout Seal Sol Type of Grout F-10ther 9 sack mix sand & cement Surface Seal Installed by Clark Pump —S) Repair Work Done Type'oi Pump Sub H.P. 5 State Work Done i -nstall Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') sept�iS;,taft pr,seepaqe pitpermitted if public sewer is 4vdi'l,able within 200,feet4H-4-�---�- Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE UNo. & Length of lines Total length/size FILTER BED Distance to nearest: Well Fourdation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distanc'e 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 -1, 9 certifies the following: "I certify thatin the performance of the work for which this permit is issued, all not em n in such manner as tG become subject to workman� compensation laws of California." 1.1y fgoobr sub contri y Per ur certifies the following: "I certify that in the performance of the work for which Contractor's hir ng sign e this permit is i �! e, a I pers s subject to workman's compensation laws of California." The applic al r ins c tions. Complete drawing on reverse side. Signed X Title: VP—Clark LIP1 I R Equip, Date;2 q 71, 3 V F PARTMENT USE ONLY Appl cation Accepted by )� - . Area �k 465-5781 A itional Comments,: Wf-,11 M.Ic+ L�� loo, -h-ary, (is,1 0 ilii Lodi 369-3621 Pit or GroVCinspect),on by -S4eji1-5'-'A el -7 Manteca 823-7104 Tracy 835-6385 Final Ins ction by- Da Final 1 . % I 1 1 1 th\Perm t/Si� on Ave. t-S11 -a`l -; -'-.\ i �vice' 6 E"s z e P.O. Box 2009, Stk., CA 95201 A pp�i c n Return' 0C pie's to . 'E'hvironme�til--�l s BASE AMOUNT". '6UE', A4WNf'�REM'1-*[! /AECEI'VEb�By "DAT FEE PERMIT NO. INFO s x EH 13-24 REV. 10/82 1 10182 500 14-26