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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE„ STOCKTON, CA I Telephone (209) 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/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 I Local Health District. I Job Address 14700 W. Schulte Rd City Lot Size 473rr�,c PM One Webster' s Landing - Owner's Namr utting/Rice PartnersYA tFess rfacusse, New York 13202-- Pnone315 471 5338 Contractor Clark Well Address 2()24 T - ("ba-ter License No.371 5C,() Phan2 7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTXRX DESTRUCTIOI�k:& PUMP INSTALLATIGWX} AXX SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 460 SEWER LINES DISPOSAL FLD. PROP. LINE -� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X"lndustrial Fire ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private 9kftravel Pack :�7kTracy Type of Casing Strap? Specifications .250 I'I Public Cl Other ❑ Delta Depth of Grout Seal I oo , Type of Grout A sack I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by C1;rk Repair Work Done ❑ Type of Pump Sib H.P. _ 30 State Work Done -_ j11S tat 1: Well Destruction ❑ Weil Diameter oo rte— Sealing Material (top 501 Depth '155 Filler Material (Below 50'19, 0'1ackP 0^ =� TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) 6 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 t PKG. TREATMENT PLT. ❑ Method of'�Disposal Distance to nearest: Well Foundation Property Line i F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line l DISPOSAL PONDS ❑ 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 I 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 certifie's the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California,- The applic ions. Complete drawing on reverse side. Signed X q Title:1112 C1 ;;r-k Wpi I Date: 4 May 90 I FOR DEPARTMENT USE ONLY E Application Accepted by Date © Area2-/ (5_ f /G Pit r Grout I pection by Date15 !O/ O Final Inspection by !Date ©rd u•e-!I � ,r 6 f if fd G C�� Ga�e�/ _ r ,C Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3w,oz rjeca' 823-71 p4 Trac 835- 8 l y 63 _ COX': 5�7-12_3' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFO FEE AMOUNT DUE AMOUNT REMITTED CASH G RECEIVED BY 0 TE PERMIT'NO a EH 13-24(REV.t i n 5) -5 1 EH 14-?8 r '� 0