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f APPLICATION FOR PERMIT F t SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZE T ON AVE., STOCKTON, CA ' ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made tdthe.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. f 5131' East' Morada Lane : Stockton Job Address City Lot Size PM Owner's Name Annajean Carrera Address 5131 East Morada Phone 464-4524 Contractor Clark Well 'Address .2024 E. Charter Way License No. 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑' ' T PUMP INSTALLATION [X SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP:.1LlW i FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS \1 INTENDED USE TYPE OF.WELL PROBLEM AREA w CONSTRUCTION SPECIFICATIONS # ❑ Industrial ❑ 0 6n'Bdttom? I,❑,Manteca ; Dia. of Well Excavation t Dia. of Well Caking ❑ Domestic/Private ❑ Gravel Pack' ❑~Tracyt type of Casing a Specifications 1-1 Public ❑ Other O'Delta Depth of Grout Seal Type of GroutA I 1 Irrigation __Approx. Depth,,,,lrl Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump Stilb H.P. 2 State Work Done Repair burnt wire . Well Destruction ❑ Well Diameter i Sealing Material (top 50'1 1 Depth 1I Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l,'l—REPAIR/•ADDITION4.1, DESTRUCTION i I (No Septic system permitted if public sewer is t available within 200 feet.) / Installation will serve: Residence ' Commercial_,,Other, t+ " r Number of'tiving units: Number of bedrooms t ` +�{ ti.► f . 3.aaiacter of soil to a depth of 3 feet: Water table depth} SEPTIC TANK ❑ Type/Mfg 1----- - -Capacity 1 No. Compartments P PKG. TREATMENT PLT. ❑ I. y _ t y. Method of Disposal Distance riear'eat: ))Nell k3 �,� ` r ,: f J i Foundation Property Line 4 r LEACFlING LINE ❑ No & Len"t �f lines Total Length size �WFILTER BED ❑ Distance to nearest: Well Foundation .- Property,Line SEEPAGE PITS f -t I `Depth Size •-� ':, t°t 1 -Nurd! rf ' r . SUMPS C1 Distance to nearest: Well Foundafion Property Line DISPOSAL PONDS ❑ m I hereby certify th ave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,f and rules and regula ons f the'San Joaquin Local Health District. r x Home owner o limns d;age ' signature"certifies the!following::"I certify that in the:performarice of the work for which this permit is issued, 1 shall not. 1 employ any p son i such ann r as to become ect tow man's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f lowin : "I ce ify th t i the r an a of th w rk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of lifor ia." � The ap lic t c I or i i c s pl t drawing_-on reverse side. "J i Signed itla: Sec-Tres Date: 26 Feb 86 FOR" F`ART74MENT USE ONLY Application Accepted by - .�� Date Area off i Pit or Grout Inspection by Date Final Inspection by zilzvzDate I) Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE CK INFO AMOUNT REMITTED CASH RECEFVED BY DATE PERMIT•NO. t + EH -24{AEV.i 14 �� 93 EH t1-28 � I