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I I • APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. 12644 S. Harlan Rd Lathrop Lot of Record Tr* Job Address City Lot Size PM Fuddle K Farms 12644 Harland 982-5575 Owner's Name Address Phone Clark Well ®AIX 371560 462-7676 Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IN DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK na SEWER LINES na DISPOSAL FLD.na PROP. LINE +30 FOUNDATION AGRICULTURE WELL OTHER WELL 10 r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI4f,TI(1� .R 6 5/811 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 9)<Domestic/Private Gravel Pack ❑ Tracy Type of Casing Steal Specifications#12 ❑ Public 11 Other ❑ Delta Depth of Grout Seal Rn f t Type of Gro a'-`17 ! . ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r 3 ar r�� Repair Work Done ❑ Type of Pump Sub H.P. 1 State Work Done 5 no+a1 1 y{,/� W30 Q�I'D struction Well Diameter Sealing Material Itop 50') Depth 4223 Filler Material (Below 50') T PE F SEPyT�,IpC, yRyK�: N INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ��f r//1 or available within 200 feet.) ��allation will serve: %aside ce_ 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 ❑ 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, and rules and regulations of the an Joaquin Local Health District. Home owner or license agent's si ure certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ a4following: on in ch er as t ecome subject to orkman's compensation laws of California."Contractors hiring or sub-contracting signature certifies t ' itify hat in t ante of t work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawsNo ia." The applit cal fo 11 a in i to dr ing on reverse side. Signed Title: VP—Clark Date: 9 Sept 1985 V� FOR DEPARTMENT USE ONLY C' Application Accepted by "✓ t(n62 Date ). Area �3 Pit or Grout Inspe ion by Date Final Inspection by - - Date Additional Commem I{1.S c4 ort 1✓( rn o/'r! r ❑ Stk 466-6781 ❑ Lodi 389-3821 Manteca 823-7104 ❑kracy 835-6385 Applicant- Return all co ies to, Environmental a Ith Permit/Services 1601 E. Hazelton Ave., P.O. ox 2009, Stk., A s� 1 S�c/C�n C icy I� 3 i+I Daily oc�� O1c� Yurw f� /Q�1ea� NFO CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. t EH 13-24 IREV.10/831 �(y� a�1r^ ^^1O —� �� joq� CJ EH 1428 11� 1-yf N1 d'