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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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/of 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. 57 .8 E Highway Stockton Job Address City Lot Size 759-13 PM Owner's Name Horace Rosalia Address P• 0• BOX 80 , Artois, CA Phone 916/865-4792 Contractor CLARK WELL Address 2024 E CHARTER WAY License No. 371560 phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS ---INTENDED US&�" -_. _ ,�TYPE`OF'WELL PROBLEM AREA^"CONSTRUCTION SPECIFICATIONS-- C71 Industrial S 7 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications � _ 1 M Public � C] Other Cl Delta Depth of Grout Sea! Type of Grout I I Irrigation -Approx. Depth [,I Eastern Surface Seal Installed by Repair Work Done C] Type of Pump ></ H.P. State Work Done_ ^ 11 Destruction Well Diameter/ Sealing Material Ito 50') C r n ff�. � 9 P Depth $� + ID ;,.Filler Material (Below 501 _ __ �S✓1N G TYPE OF.SEPTIC WORK: NEW INSTALItATIBN I.i REPAIWADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is j available within 200 feet.) Installation will server:- Residence_ �Gorn'nercial •1 Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: +' Water table depth SEPTIC TANK p Type/Mfg iF,Capacity No. Compartments PKG. TREATMENT PLT. Method of Disposal Distance to b reit: Well Foundation ;" ,Property Line LEACHING LINE g C;I No. & Length of lines LYS. Total length/size ! FILTER BED , ❑ Distance to nearest.. Well .Foundation T Property Line t SEEPAGE PITS 1 1 1 Depth Size - y"a �� _ Number SUMPS LC Distance to nearest: Well 4;FoJdation P�ropertjy Line DISPOSAL PONDS 1 6 I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t 4 Home owner or licensed agent's signature certifies the following: "I certify that in thefperformance of the work for which this permit is issued, I shall not employ any p on in such manner ss to become subject to wofkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f II wing:i"I cc it that in the rforman of the work for which this permit is issued,I shall emloy persons subject to workman's compensa- tion laws of a fomia." : The applic t cal I uir i c ions. mplete drawing on reverse side. t Signed x ______Title: ; Sq-Tres t om_ Date: July 15, 1988 FOFi btPARTMEKT- USE ONLY Application Accepted by r Date 1. Area Pit or Grout Inspection by, Date Final Inspection by Date Additional Comments: y � Y" ❑ Stk 466-6781 t .L,dr 369-361 ❑ Mantec 823-7104 ❑ Tracy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTEDCASH CK 9 RECEIVED BY DATE PERMITNO. EH 1324IREV. /x51 7 /sem �f EH 14-26 y