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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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 11052 East Weigum City Victor Lot Size 15 Acres PM Owner's Name Tony TsappisAddress 9128 Rutland Phone Contractor's Name Clark Well License No., 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION _� J SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 00 sew SEWER,LINES DISPOSAL FLD. PROP. LINE200 FOUNDATION AGRICULL-T-URE WELL 100 r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 39CGravel Pack ❑ Tracy Type of Casing 'Steel Specifications #1 2 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50 r Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Clark ry Repair Work Done ❑ Type of Pump Sub H.P. 3 State Work Done-AIMS t a 11 Well Destruction ❑ Well Diameter Sealing Material (tap 501 Depth Filler Material (Below 501 �y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is C-1 available within 200 feet.) Installation will serve: Residence_ 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 C� PKG. TREATMENT PLT. ❑ C Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total ien9 th/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 7; DISPOSAL PONDS ❑ r 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 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."Contractor's 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 n-wst All fo qu e n ti s. mpl a drawing on rpv rse side. Well VV Clark 8 July 88 Signed. Title: Date: tn!!TMENT USE ONLY Application Accepted by . Date Area Pit or Grout Inspection by Dat "� Final Inspection by 4.4 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Sefvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.101831 1 S �� EH W26 r J