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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.8781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rli Action is hereby nude to the San JosquIn Local Health District for a permit to construct and/or WOW the work herein described.This application is Is in compliance with San Joaquin County Ordinance No.S*for sewage or No.IOU for well/pump aro the Rules end RoWletion a of the San Joaquin al Health District. Agars. 2444 East Lathrop Rd �mLathrop Lot size 20 acres PM ners Name Con Fab _ Aaldress PO Dox 1369 Phone 658-2521 tractor Clark Well Address 2024 E. Charter License No.371560 Phone 462-7676 'E OF WELL/PUMP: NEIN WELL Xk WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION XD( SYSTEM REPAIR ❑ OTHER ❑ iTANCE TO NEAREST: SEPTIC TANK 400 F SEWER LINES _ DISPOSAL FLD._ OP. LINE —120 f t FOUNDATION AGRICULTURE WELL OTHER WELL PI S/SUMPS �• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ^'ISA' I• Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation 1 tlZ.,Wall Cae 2 0 5 8 Domestic/Private N Gravel Pack ❑Tracy Type of Specifications Public ❑Other ❑ Def& Depth of Grout Seal Type of Grout 9 s a to k Irrigation —Approx. Depth ❑Eastern Surface Seel Installed r k pair Work Done ❑ Type of Pump Sub H.P. 5S ork Dona Install A Destruction ❑ Wall Diameter Seawv Material(top 50') Depth_ Fd*Material IBelow 50') PE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION❑ (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence— Commercial— Other j Number of living units:__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth_ :PTIC TANK ❑ Type/Mfg ___ Capacity _. No. Compartments ,G. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation- Property Line ACHING LINE No. & Length of lines _ _ _ Total Length/size LTER BED LDistance to nearest: Well Foundation Property Line EEPAGE PITS Depth Size Number JMPS Distance to nearest: Well Foundation Property Line ISPOSAL PONDS C il hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, ang rles and regulations of the San Joaquin Local Health District. orae owner or k 4 need agent's signature certifies the following:"I certify that in the performance of the work for which this permit is awed,I shay not mploy any person in such manner as to become subject to workman's compensation laws of California.-Contractors hiring or sub•contrecting signature ortrfies the follovring:"I certify th ortnance of the ywork for which this permit is issued,1 shell employ persons subject to workman's comperes- on laws of Caldonrw." he applrcany/ �j r IrAll l drawing on reverse side. ;Igned X __ — Title: _V_R-C]ark Well Date: _2 3 O C t 1986 FOR DEPA TMENT USE ONLY 01 1pplication Accepted by _. � Date La- Ares /3 _ 7 'rt or Grout Inspection by Dste�4� 7 iif ! Final by -00 Ins Dow�ddrtrorial Comments �A"A `""' �y� Stk 466-6781 Lodi 360.3621 Manteca 823-7104 f Tracy 836+3385 �ppl,cant - Return 611 copies to: Envvonniental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 85201 FEE AMOUNT DUF AMOUNT REMITTED Cite RECEIVED By DATE PERMIT NO. IN40 y CASH