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;;PPLICATION FOS PERMIT SAN -TCAQL:N LOCAL HEALTH DISTRICT 1601 E, RA'ELTON AVE., STOCKTON, CA PERMTT NO. Telephone (209; 466-6781 PER^ DATE ISSUED ;T 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/or install the work herein described. This application is made in compliance with San Joaquin County Or nance No, 549 for sewage or No. 4812 for well\/pumI and the Rules and2. Regulations of the San Joaquin Local Health District. �' 3tI:` w i 1 -, 4_. Job Address Z Ili Subdivision Name - Owner's Name bave, Hirsch _ Address 6669 EIl^barc dero Dry—rte, Phone g57-880 Contractor's Name Clark Well License No. 37156o Phone 462-5D7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F-1 DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR I OTHER L—I w DISTANCE TO NEAREST; SEPTIC TANK + 50 SEWER LINES DISPOSAL FLU. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L Industrial U Open Bottom I ; Manteca Dia. of Well Excavation 10 548 i' J Domestic/Private Gravel Pack Tracy Dia. of Well Casing _ 5/8" �J ' Public LJ Other ❑ Delta Type of Casing 12 S t.Q e l IrrigationApprox. Eastern Depth Specifications Cathodic Protection p — - Depth of Grout Seal LlGeophysicai �Q Other Type of Grout 9 Sack Tr11x(Sa.nd Cement Surface Seal Installed by C lark Repair Work Done D Type of Pump Sub 14,P, I State Work Done Install _ Well Destruction U Well Diameter 6 5 A-11 Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) r` Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth yJ SEPTIC TANKT e Mf r LJ YP I 9 Capacity No. Compartments ✓) PKG. TREATMENT PLT, U Type/Mfg Capacity Method of Disposal V SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED L Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Numher SUMPS Lj Distance to nearest,- Well Foundation Property Line DISPOSAL PONDS D J� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county tJ 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 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is iss ,_.� shall employ persons subject to workman's compensation laws of California." The applicant st call for. aT r aired in ections. Complete drawing on reverse side. Signed X ' C i" % _ Title: warner Date: _9 Ma1�3 FQ}Z DEPARTMENT USE ONLY Application Accepted by /� %Gi y�Clc.r.--- Area C Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection b iR Date 5 U Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-5385 Applicant - Return all Copies, to: nvironmental Health Permit/Services 16 1 F. aze ton Ave. , P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NLS. INFO — _ EH 13-24 REV. IO/B2 10/82 500 14-26