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APPLICATION FOR PERMIT <br /> SAN JOAQU;N LOCAL HEALTH DISTRICT �7•?J—�� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 66-7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ane,/or install the work herein <br />~ described, This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address 8775 East Live Oak Rd me <br /> Owner's Name Mro Arnold Nelson Address 5797 Ravenwood Ave . Phone 415-793-277 <br /> f Contractor's NameClark Well & Eguip.License No. 371560 Phone 4625597Cb <br /> _A <br /> i <br /> ,TYPE OF WELL/PUMP WORK: NEW WELL ® WELL REPLACEMENT DESTRUCTION <br /> ! PUMP INSTALLATION SYSTEM REPAIR I[J OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK — 1351 SEWER LINES DISPOSAL FLO, PROPI LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED`USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V 1�1 <br /> 0 5/871 <br /> h_11ndustrial U Open Bottom Manteca Dia, of Well Excavation <br /> F�Domestic/Private )(& Gravel Pack Tracy Dia. of Well Casing 6 _r-,/Rif <br /> I 1-:] Public F-1 Other ❑ Del to Tyof Casing # 12 S to e 1 <br /> LjIrrigation Approx. � Eastern <br /> Depth Specifications ifications T <br /> F-1CathodicProtection Depth of Grout Seal <br /> 0 Geophysical <br /> Type Grout <br /> F-1Other er <br /> Surfacece Seal Installed by <br /> Repair Work Done Q Type of Pump 1 H.P. 51J b State Work Done <br /> lWell Destruction ❑ Well Diameter Sealing Material (top 50') 1 <br /> k Depth Filler Material (Below 50') I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION j J (No septic tank or seepage pit permitted if. public sewer is <br /> — available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table-depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments , <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> + SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION Q <br /> LEACHING LINE U No, & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS A.yDepth Size / Number <br /> SUMPS II !Distance to nearest: Well" Foundation Property Line <br /> 'rD]SPOSAL`PONDS _,.CIS- -------._.��� { <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> k The appiica t must call a iir inspections. Complete drawing on reverse side. <br /> Date: Jul y 19$_ <br /> Signed X Title: <br /> DEPAR ENT USE ONLY ❑ <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: Lodi 369•-3621 <br /> Pit or Grout Inspection by Date ,g��aa�� Manteca 823-7104 <br /> Final Inspection by Date '3 'Z 63 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Serv4*���ices 160 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH I3-24 REV. 10/82 500 <br /> 14-26 <br />