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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL H;ALTi' DISTRICT tt f 1501 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 L g` DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (JO (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 V 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 1642 SONORA Subdivision Name Owner's Name CALIF. CEDER Address 1340 W. WASHINGIQN Phone Contractor's Name WORLD ENTERPRISES License No. 265964 Phone 466-07 17TYPE OF WELL/PUMP WORK: NEW WELL F-1 , WELL REPLACEMENT" E DESTRUCTION PUMP..INSTALLATION ❑ SYSTEM REPAIR v -... OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ./1 IJ Industrial U Open Bottom Manteca iDia. of Well Excavation U Domestic/Private Gravel Pack Tracy Dia, of Well Casing Public F-1 Other Delta Type of Casing Irrigation Approx. Eastern Depth Specifications Cathodic Protection Depth of Grout Seal L7 Geophysical Type of Grout Lf Other Surface Seal Installed by Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') .. .•ru TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line � ON LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line 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 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 isP1, d, I sh 1 employ persons subject to workman's compensation laws of California." The applican m all re fired inspections. Complete drawing on reverse side. Signed X Title}/ Date: OR DE TM USE ONLY Application Accepted by /l Area C 1' Stk 466-678I Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all collies to: viro ntal Health Permit/Services 1fi01 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BYDATE PERMIT NO,FO r ¢) )vu`s (O 7 �{�o LH 13-24 REV. 10/82 d� 10/82 500 14-26