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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) $3-��{� PERMIT NO. DATE ISSUED 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. l Job Address 8775 East Live Oak Rd--5vb,�-Name owner's Name Mr. Arnold Nelson Address . 5797 Rayenwood Ave. Phone 415-793-277 t Contractor's NameClark Well & Equip-, icense No. 371560 Phone 4625597__ (TYPE OF WELL/PUMP WORK: NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION ❑ ! PUMP INSTALLATION [] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1351 SEWER LINES DISPOSAL FLO. PROP4 LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing o FF, Rrr I ❑ Public ❑ Other ❑ Delta Type of Casing # 12 5 t e el Irrigation Approx. [] Eastern Specifications (� ❑ Cathodic Protection Depth -- Depth of Grout Seal ❑ Geophysical Type of Grout 71 Other 8 Surface Seal Installed by { Repair Work Done[] Type of Pump 1 H.P. 5 u 6 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 _ E Depth Filler Material (Below 50') 1 If TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if. public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size t Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK [] Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal ' SEWAGE SYSTEM Distance to nearest- Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS ❑ Depth Size ,/ _ Number 1 "� SUMPS ' U Distance to nearest: Wel 1'!�tion Property Line \ �DISPOSAL'PONDS .�...❑I�� f V 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 employ any person in such manner as to become subject to workman Is compensation laws of California." Contractor's hiring or sub -contracting 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 compensation laws of California." The applicaAmust call a iir inspections. Complete drawing on reverse side. Signed X Title: QidCles: Date: 1 DulY 198_ 0 DEPAR ENT USE ONLYy / Application Accepted by Area L! / ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Datej ZL1J [_j Tracy 835-6385 Applicant - Return all copies to: Environmental Health PermitJServices 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EH 13-24 REV. 10/82 z%,>^(calf 500 14-26 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 z%,>^(calf 500 14-26