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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 If r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (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 346 FRESNO City STOCKTot Size PM Owner's Name CAL CEDER Address P.O. BOX 528 STKN Phone — 5800 Contractor's Name WORLD MMRPR15YS_, rase No. 265964 Phone 466-0717 ` W TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 6— FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS g I 11 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavafion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingi I. Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout } ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ElType of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION.X {No septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms r f j l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKC. TREATMENT PLT. ❑ ' Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines { Total length/size FILTER BED El Distance to nearest: Well ; Foundation N F Property Line SEEPAGE PITS ❑ Depth . Size Number SUMPS Ll Distance to nearest: Well Foundation # Property Line DISPOSAL PONDS ❑ t "imill 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 l employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in theeerformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." F 1 The applicant r all req 'ed4ct! s plete drawing on reverse side. I t Signed Title: SECRETARY Data: 5-17-84 I OR DEPARTMENT USE ONLY Application's Accepted by Date 17— Area Pit or Grou Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6355 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'NO. INFO ii + EH 13-24(REV.10!531 [ " J �Y �`�114 EH W26