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APPLICATION FOR PERMIT a ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 8,3— �- Telephone (209) 466-6781 IE'D' DATE ISSUED 93 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED li (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 11243 N Hams T-ane _ Subdivision Name Owner's Name Address] Florin-Perkins Rd Sac Phone Contractor's Name Clark ell( License No. 1 b 0 Phone �•f UJ TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION EZ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "F f FOUNDATION AGRICULTURE WELL i + OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ In ❑ Open Bottom ❑Manteca Dia. of Well Excavation 2 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public: ❑Other; 0 Delta Type of Casing Irrigation Approx. [] Eastern Specifications ❑ Cathodic Protection Opth Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter t " Sealing Material (top 50'} C m i X Depth Filler Material (Below 50')� s an 1= WWWWW—W.InA U3 TYPE OF SEPTIC WORK: NEW INSTALLATION [_J REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other i 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 Capacity Method. of Disposal i PKG. TREATMENT PLT, E] Type/Mfg t Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance(to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's * ture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shat of emp y any person in such manner as to became subject to workman§ compensation laws of California." Contractor's hiring o sub-contrac ing ignatu certifies the following: "I certify that in the performance of the work for which this permit is iss e I 1 em p rsons bject to workman's compensation laws of California." The applican u ca eq r i s i ns. Complete drawing on reverse side. Signed X Title: _ Date r RTMEN VE ONLY Application Accepted b Area ❑ Stk 466-67$1 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date 7 Q Manteca 823-7104 Final Inspection by Date I Z 3 Q Tracy 835-6385 Applicant - Return all copie to: Environmental Aalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � a FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 5 �3 <93-3 EH 13-24 = REV. 10/82 10/82 500 14-26