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`r APPLICATION FOR PERMIT `.+ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. IP62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 147-09 Wit SSehulte d City _ Lot Size 47 Anre= PM �9uttin Rice One Webster' s Landing Owner's Nam g� PartnersWtpsseCvrar,,,se m.,... y....l. 3202 Phone contractor Clark Wel 1 Address 7024 P. charter License No.4�-1-54&O_Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTXVCX DESTRUCTIOI*k�A PUMP INSTALLATIOXX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 4601 SEWER LINES DISPOSAL FLO. PROP. LINE -5-4-L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Xk�llndustrisl Fire ❑ Open Bottom ❑ Manteca Dis. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 2Qtaravel Pack jC7gTracy Type of Casing Cf-oc1 Specifications ,250 1'1 Public n Other 71 Delta Depth of Grout Seal 1 n0 E Type of Grout 9 Sack I I Irrigation __Approx. Depth I I Eastern Surface Sedl Installed by C1 ar-k Repair Work Done 0 Type of Pump rElb H.P. 30 State Work Done Ll�S tail Well Destruction ❑ Well Diameter -o n Sealing Material (top 501 Depth iR5 Filler Material (Below 501 P z+ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) d Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth C. SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 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 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 D3trict. 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 subcontracting signature certifies 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 applicant us f al r u'fbd ins Ions. Complete drawing on reverse side. Signed X Title:11P l Wi; 1 1 Date: 4 May 90 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 7-145 Pito Grrr pection by �,;,te�•4��--��IlDate '�/I O Final InspeLction by Lac- 'late Additional Comments: o/d r"K tl da C �'' C'(�r 'FD `!n L�(src Well ❑ Stk 4666781 ❑ Lodi 369-uozI antecs 823-/104 J Tracy 835-63 0 CCS j'•2—/L3 �' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -30S \SO r" 1 =L. S fJ �>G� FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO CASH EH 334IREV Ana 5 -3GSq EH IM �j p O- O O