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APPLICATION FOR PERN'17 SAN JOAQUi!: LOCAL HEALTH DISTRICT j 314 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, O J Telephone (209) 466-6781 r uoi DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplica-ce) 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 233 MADRRA S'T`OC'.KTON Subdivision Name Owner's Name CALIF- F.DF.R Address 1240 W WA 2NINGTON Phone944-5800 Contractor's Name WORLDFNTFRPRTSFfiLi cense No. _.. - — Phone 466-071.7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U vi PUMP INSTALLATION SYSTEM REPAIR OTHER Fl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial U Open Bottom F-1 Manteca Dia, of Well Excavation Domestic/Private ❑Gravel Pack F-1 Tracy Dia, of Well Casing Public -J Other ❑ Delta Type of Casing F�llrrigation Approx. d Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal L7 Geophysical Type of Grout J Other Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') , Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION Fj (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAG TEM Distance to nearest: Well Foundation- Property Line DEST ION LW — ef LEACHING LINE No. & Length of lines Total .length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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§ 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 emplp persons subject to workman's compensation laws of California." The applican m c fW all required inspections. Complete drawing on reverse side. Signed X Titl Ni P.rp Date:/ WR DE TME USE ONLY Area 4 �tk 466-6761 Application Accepted by Vim'{> ']1� .s n..w = Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection b Date LJ Manteca 823-7104 Final Inspection by Date �7/ 3 ❑ Tracy 635-6385 Applicant - Return all copies o: �vironm�entalalth Permit/Services 1601 E. Hazelton`Ave., P.O. Box 2009, St k., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO f �� 93 -17) 4 EH 13-24 REV. 10/82 G/� 1. 10/82 500 14-26