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� - APPLICATION PERMIT FOR &IK �R SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) n. 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.,. N13,te! Owner to abandoned old well Job Address 391 1 5• Wil hoit ' city Stockt©Rot size '28 iacres PM a Owner's Name Bob.,Hirsch Address 3981 S• Wi.lhoit Phone 4 48--5173 Clark Well & Equipment 3715617 4,x52-7576 Contractor's Name t License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK —+I f1I(In I SEWER LINES DISPOSAL FLD. PROP. LINE ti X26 r FOUNDATION AGRICULTURE WELL OTHER WELL—15 5 f PITS/SUMPS'-_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI _ tt ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Cising ��$ti t Domestic/Private 6 Gravel Packl ❑ Tracy Type of Casing-p VC Specifications cl 160 C] Public ❑ OtherIX Delta Depth of Grout Seal t Type of Grout' ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ; ❑ Type of Pump# H.P. State Work Done Well Destruction El Well Diameter{ Sealing Material (top 50') Depth ) -Filler Material (Below 601 Y k 0 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if)ubiic sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other N 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 ` M PKG, TREATMENT PLT. ❑ Method of Disposal r" Distance to nearest: Well l ` Foundation Property Line i LEACHING LINE 1-1.. No. & Length of lines 0_ 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 ❑ L. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinares, state laws, and rules and regulations of the- uin Local Health District. Home owner or licensed gent's signatu rt'rfies the following: "I certify that in the performance of the work for which this permits issued, I shall not employ any person in su ma er as to ubject to workman's compensation laws of California."Contractors hiring or sub-ontracting signature certifies the following:"I t t in r ance of the work for which this permit is issued, I shall employ persons subject to wrkman's compensa- tion laws of Calif rnia." The applicant t r I d I pec' ete dr ing on reverse side. Signed VP—Clark IUP' Feb '1986 [ Title: Date: 1 FOR DEPARTMENT USE ONLY ` Application'Accepted by 4 Date J6 Area e v r c Pity To InVection by/� Date'1l 'ted L Final Inspection by Date (nrGU Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ;. 1 FEE AMOUNT DUE AMOUNT REMITTED CA INFO SH RECEIVED BY DATE PE!MIT"NO. +EH 13-24(REV.10/83) EH 14-26 a O i