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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES TYEAR FROM DATE ISSUED .... �- uJAr i (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 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. . 5 Mile E of Hwy 99 , . 2 M S of 8 Mile Road Job Address MORADA ESTATES DEVELOPMENT city Stockton Lot Size PM 2 0 E Orangeburg Ave Owner I s Name Zagaris Management Address Modesto , California Phone 522-9472 Contractor Clark Well Address 2024 E Charter Wa..y License No. 31756a Phone 462_17676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 PUMP INSTAL ION SYSTEM REPAIR ❑ OTHER IX Test BOY'e _;...�. DISTANCE,TO NEAREST:_AEPTIC TANK r SEWER LINES. I DISPOSAL FLO. PROP- FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LJOpen Bottom,: I .¢' 11Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private + ❑ Gravel*Pack ` ❑ Tracy Type of Casing Specifications i [1 Public (A Other Fl Delta ,{ Depth of Grout Seat Type of Grout 1 1 Irrigation --Approx.. Depth I I Eastern "i Surface Seal Installed by Repair Work bone'" ❑? #Type.of Purnp Y H.P. t State Work Done _ dL Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION.11 REPAIR/ADDITION l I DESTRUCTION I i (No septic system permitted if public sewer is 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: . I 1 ' Water table depth F f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.-TREATMENT PLT. ❑ Method of Disposal = Distance to neatest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size _ \ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property.Line t 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 Di%trict. t 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's 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 compensa- tion laws o o,ornia." Theapplica st call f a uire i ctions. mplate drawing on reverse side. Signed X Title: Sec-Tres Date: 1,7 NOV .88 t FOR DEPARTMENT USE ONLY Application Accepted by Date Area Date 6�y Final Inspection by Datu"I -F Pit or Grout Inspec p V � s Additional Comments: ' ❑ Stk 466-6781 ❑ dodi Y69-5621 ante 823-7144 ❑ T, 835-6385 Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH i.EH 1324(REV.1/H 5) � g'g '23'e-30 EH 14-26 t