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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. I-IAZELT ON AVE., STOCKTON, CA ` r� ^ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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. Job Address 22X'L AUfk 462 W_ Downing _ City qf-nr_ktnn Lot Size 5Q X I PM Owner's Name Mike Sell= Address 22 Marilyn _ Phone 957 5278 Contractor C'_71 ark .We 1 _ _ Address C:hq:'�.. _ License No. Phone 462— TYPE OF WELL/PUMP' NEW WEIL� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION}CRX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK —( SEWER LINES I_2_01_-..-_—_, DISPOSAL FLO. j PROP. LINE 25 , I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ii ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �2 n )Dia. of Well Casing 5/0 11 iGravei Pack ❑ Tracy Type of Casing pts (Specifications CL 1 6 0 / ['I Public 1 R Other F Delta Depth of Grout Seal 100 t !Type of GroutrQ� I I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by C1 rk i _ Repair Work Done ❑1 Type of Pump Sub H.P. 3/4State Work Done Well!Destruction ❑E Well Diameter Sealing Material (top 50') { !f l Depth f Fillet Material (Belriuv 501) t __ TYPE OF SEPTIC WORK:_»NEW INSTALLATION IJ_ REPAIWAIDDITION l 1 rOESTR.UCTION It] Wo septic system permitted if public sewer is J - _ available within 200 feet-1 Installation will serve:E.R.esidence "' Comm6rcial " Other ►r, � !1 irt ar 1 r Nurnber{,of living units:/ Nur�tber of bedrooms Giaracter of soil to a depth of 3 feet: Water able depth T SEPTIJITANK ❑ Type/Mfg � Capacity No. Compartments PKG. TREATMENT PLT: ❑ Method of Disposal F r-�._ l Distance to nearest: Well Foundation Property Line �* i� LEACHING LINE 1 ❑ No. & Length of lines Total length/size FILTER BED ; ❑ Distance to nearest: Well Foundation Property Line 3 ; SEEPAGE PITS j i I Depth Size Number ' SUMPS ❑ Distance to nearest: Well FoundationProperty Line 1 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 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 1 -- employ-anV.person-in-such-manner-as-to-become-subject-to-workman's-compensation-laws-of-C-alifornia.--C-ontractor's-hiring or-sub-contracting'signature r/ 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 compensate tion laws of Califo a." The applicant c i o aEl ;?e�* VP C1ark].Well ctio Complete drawing on reverse side. Signed X Title: Date: 5 Apr 90 d MENT USE ONLY Application Accepted by "`'�'� "` Date Area Ssi� Area Pit or Grout Ins ction by Date r6 Final Inspection by -�y�/ Date r Q r Additional Comments: { t�r^` 6D ❑ Stk 466-6781 ❑ Lodi 369-3p 1 CyManteca 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 CCK 0 RECEIVED BY DATE PERMIT NO. q r7c, b- oEH 1t 28 IREV.t i k51 '� � � 8-0-:S