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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUEO M�T PERMIT EXPIRES i YEAR FROM DATE ISSUED 1 (Complete in Triplicate) L� Application is hereby made to the San Joaquin Local Health Distrrict 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 0a and the Rules and Regulations of the San Joaquin Local Health District. Job AddressMADERA Subdivision Name Owner's Name CAL_I , CEQEE . Address 1340 W- WASHINGTON phone 944—")800 Contractor's Name WORLD ENURPRISES, License No. 265 }64 phone466—n7 1_7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom F Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack Tracy Dia. of. Well Casing Publ i c [j Other Del to Type of Casing Lj Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Other Type of Grout y1 Surface Seal Installed by Repair Work Done [J Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION i J (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 Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal SEWAGE $ZSTEM Distance to nearest: Well Foundation Property Line DESTRUCT LEACHING LINE [J No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS E1 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 sh 11 employ persons subject to workman's compensation laws of California." The applica t 11 r all required inspections. Complete drawing on reverse side. 01 Signed X Titl6V/�_pF2T'-qTT1F'NI Date:/ F R DE TM USE QALY Application Accepted byArea 1� Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Ll Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: En vi onmental Hea h Permit/Services 1601 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �4 l i-�3 t EH 13-24 REV. 10/82 1 �'1 V�e�� _ _10/82 500 14-26 ll4�