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APPLICATION FOR PERMIT SAN, JOAQUIN LOCAL HEALTH 7iSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456-6781, DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,,, (Complete in Triplicate) O�C?�; Application is -hereby made t th San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application 1s made in compliance with San Joaquin County Ordinance No. 549 for sewage.or No. 1862ifor well/pump and the Rules and Regulations of the San Joaquin Local,Health District.. 1 Job Address 'Mi 1a W :of.. Gil1.is & H9y_4 Subdivision Name Owner's Name MT+ Rey Camera Address ,1455 Gillis rd lKone 464 1727 Contractor's Name Clark Well, & Equi 'License No. 371.560 Phone 462-5597 l f TYPE OF WELL/PUMP WORK: NEW WELL ) WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION 71 SYSTEM REPAIR Ej OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE . 50 F U B ULTU ILL 200' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Fj Industrial U open Bottom [] Manteca Dia. of Well Excavation 26" U Domestic/Private ® Gravel' Pack [�Tracy Dia. of Well Casing loll Public LJ Other f] Delta _ •'250 Steel V Irrigation Approx. Eastern Type of Casing Depth Specifications Cathodic Protection p Depth of Grout Seal ��B 1--1Geophysical U Other ��, Type of Grout `1 L104u, Surface Seal InstalledbbyyRepair Work Done Type of Pumpp, State Work Done _ —1r,QZL tfM Well Destruction ❑ Well Diameter Sealing Material (top 50') �. Depth Filler Material (Below 50') II TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Cbmmercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation' Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED . ,Distance to nearest: Well Foundation Property Line SEEPAGE PITS #❑ Depth A Size Number 5 SUMPS L—� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I' I hereby certify that I have prepared this application and that the work will he 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 agen ' ure certifies the following: "I certify that in the performance of theworkfor which this permit is issued, I shall n mploy son in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub o rac s' n ture certifies the following: "I certify that in the performance of the work for which this permit is is ued, I hal e y pe so s subject to workman's compensation laws of California." The applican ca or 11 a aired i p c io s. Complete drawing on reverse side. Signed X Title: VP—C1ark 1,1P.11. Date: 9P4a Gh 19Z4 EP MEN SE ONLY Replication Accepted by Area —y—�� Stk 466-fi78 Additional Comments: Tl7�f�dl{/` Lodi 369-3621 Pit or Grout Inspect' n by Date LJ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all co ies t Environmental HeaI h t/Services 1601 E. azel on Av P.O. Box 2009, St CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RE EIVED 8-Y DATE PERO NO. , INFO � �- ►�� 3 z� g� z� 1 EH 13-24 REV. 10/82 I0182 500 14-26