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1 �. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 4 81 4 East Washington City St'kn Lot Size - 1 .12 Ar-ra PM Owner's Name Tony Arceo Address 1 027 S. Golden Gate Phone948-451 4 Contractor Clark : Address 2024 East Charter License No. 3715 6-0— Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTfONft PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-0- DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES DISPOSAL FLD. PROP. LINE +1 O r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ll Other 17 Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump - H.P. State Work Done_ Well Destruction t$X Well Diameterr8_1- Sealing Material Itop 50') gSar-k-Mi x Depth 130 Filler Material (Below 5011 Sr ME? _. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di"strict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I 'n the performance of the work fpr which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of Cali rnia." The applican I or Zq .d ete drawing on reverse side. Signed X Title: V p Clark Date: 9 Sept 8$ F R T--USE ONLY Application Accepted by Date ` \~ Area Pit or Grout Inspection by Date Final Inspection b Date ?�w Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i IFEEO AMOUNT DUE AMOUNT RE ITTED CASK RECEIVED BY /D�ATEr' PERMIT*NO. iEH EH14281REV.fir551tp� `J