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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. '��.11-W Telephone (209) 466-6781 DATE ISSUED —7/17/ 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 Local Health District. Job Address 266 W. Manila Rd Subdivision Name 9155_ 00 Owner's Name Eddie Moises Address 266 W. M a m i a Phone �04U/ l Contractor's Name Clark Wel 1 License No. 371bbU. Phone 462-5597 1 TYPE OF WELL/PUMP WORK: NEW WELL ®C WELL REPLACEMENT Ej DESTRUCTION❑ 5 _: PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK +1001 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation 100 33-/4411 Domestic/Private E]Gravel Pack F-1TracyDia, of Well Casing 10 `�1y" 0 Public F-1 Other Delta Type of Casing .188 Steel EX Irrigation Approx. Eastern Specifications E3Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout Other L7 ` � , I Surface Seal Installed by Clark 1 Repair Work Done E] Type of Pump`1'1a{` ,1�-H.P. /o /V n State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L) REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) C Installation will serve: Residence Commercial Other C 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. Cc-oartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal 9 SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 5, DESTRUCTION f. LEACHING LINE U No. & Length of lines Total length/size J r FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number 'p 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 oy any person in such manner as to become subject to workman!;compensation laws of California." Contractor's hir'ng or su - tr sign sure certifies the following: "1 certify that in the performance of the work for which this permit su , 1by ers subject to workman's compensation laws of California." The appli td pections. Complete drawing on reverse side. Signed Title: — tDate: gr -1 T._ AT OR DEPART ❑ Application AcceArea ((Ir - Stk 46fi-6781 fulditional ComneO Lodi 369-3621 Pit or Grout Ins Date LJ Manteca 823-7104 Final Inspection by �7 Date D LI Tracy 835-6385 Applicant - Return all copies to: Envirmenth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ontal Heal FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 7R�1 w 83 71O'/8'Z s00 EH 13-24 REV. 10/82 14-26