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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. 2361 Section Job Address City Stockton Lot Size 1/2 PM Owner's Name Diesel Truck Se-rvice Address 2327 East Mariposa Phone 464-7379 Clark Well Contractor Address 2024 East Charter License No.371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL Lel WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ;J SYSTEM REPAIR ❑ OTHER ❑ 101 DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial t1 6 5/811 �98 j ❑ Open Bottom ❑ Manteca Dia. of Well Excavati Dia. of Well Casino Specifications 2 1 XX Domestic/Private ® Gravel Pack ❑ Tracy Type of Casing � i 1 Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout 9 sack I I Irrigation ,-._Approx. Dench I I Eastern 1Su 7i L Seal installed by ar Repair Work Done ❑ Type of Pump H.P. iI�� State Work Done Lnstar1 Well Destruction ❑ Welt Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ts" TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l I DESTRUCTION I } INo septic system permitted if public sewer is available within 200 feet.) a^ I Installation will serve:'' Residence_ Commercial_ Other' i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D 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 Ll Distance to nearest: Well foundation Property Line i 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 y 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant c f r it d i ti . Com late drawing on reverse side. .Signed x Title: VP—Clark Well Data. 7 Oct 1987 FOR DEPARTMENT USE ONLY w Application Accepted by Date /© k t / Area Pit oro u Inspection by ate Final Inspection by Date 6d 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.I/H s) EH 1I-26 4r/f({y' '/,/p]� s C'-'