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f , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .F n (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 fn 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, Soo S. Morada-100' tJ. Cole 'Drive Stockta Job° ddress z city fat Size PM-_ a Owner's-NameDelta Dexi elopment 4 Address PO=741.4 Phone 3 _Clark °W-dirl �...; � o, F 462-5597 License Nn. Contractor's Name iI J -�� a+. _ r' Phone TYPE OF WELL/PUMP: NEW WELL ❑'' ,WELL REPLACEMENT'❑ y DESTRUCTION x PUMP INSTALLATION 'tet SYSTEM REPAIR ❑,- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150 r SEWER LINES i_ - r''-DISPOSAL FLD. PROP. LINE ' FOUNDATfON a. AGRICULTURE WELL _ OTHER WELL �Ulj' 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 a. ❑ Public, ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation G g ---Approx. t ❑ Eastern Surface Seal Installed by Repair Work Dona ❑ Type of Pump H.P State Work Done Well Destruction ❑ Well Diameter iSealing Material Itop 50'1 �{ Depth_ { r Filler Material 4B IoW 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ £DESTRUCTION ❑ (No septic system permitted if public sewer is u.{ s available within 200 feet.) Installation will serve: Residence Commercial Other. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: "" - - Water table depth f -� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ; PKG. TREATMENT PLT. ❑ f. 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 ❑ Depth Size Number SUMPS t ❑ 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 m neer as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:" rtify t a t rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cali rni The applica st II f r I ire in ct ns. Complete drawing on reverse side. -� Signed Tale: VP—Clark May 241985 ate: F K � FO P RTMENT USE ONLY CU c l Application Accepted by _ -• Date ea Pit or Grout Inspection by y-16PE� � Date Final Inspection by DateCrJt! Additional Comments: ❑ Stk 466-6761 El Lodi 359-3621 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATF �,_ PERMIT`NO. + EH 13-24(REV.10183) EH 54-26 /Zq S Eo