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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin ' Local Health District. Pre-72 4734 East Woodbridge Rd City Acre mpo Lot Size z A Job Address PM RaY & Edith Wilson same 368-6034 Owner's Name Address Phone Contractor Clark Address 2024 E. Charter License No. 371 560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN7XR9X DESTRUCTIOWNXX PUMP INSTALLATIONXXX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK +50 r SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL^7r r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing 6 5 8 rr XR Domestic/Private xfkGravel Pack ❑ Tracy Type of Casing_C f-ora 1 Specifications #10 M Public F Other F1 Delta Depth of Grout Seal 350 Type of Grout 9 saCk I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Clark _ Repair Work Done E Type of Pump Sub . H.P. 1 State Work Done _iris tall Well Destruction C Well Diameter Gtr Sealing Material {top 501 _ qa-k Depth »k_nown Filler Material (Below 501 'r TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is tN 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 PKG. TREATMENT PLT. ❑ Method of Disposal d Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 pe ante of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cali rnia." The applican c for re in cti m ete rawing on reverse side. c+,vr+w--------— Signe- 01.4 Title: VP Date: 18 Oct 1988 FOR DEPARTMENT USE ONLY Application Acce d by �q ( Date A% Area_ to Pit or Grout Inspection by Final Inspection by � Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 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 SASH RECEIVED BY DATE �PEERMIT'NO. +.EH 1324 MEY,t i R 5) �"�0 EH 14-26 f SCS S^��CA9