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i bn APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Job Address N.orthcact Corner, Main & Alameda Sts. city Manteca Lot Size 75f X 50ft PM P.O. Box 1007 Owner's Name Royal Oaks Savings Address MAntara,_CA CIS116 Phone -1155 6551 S. Revere Pkwy. , Ste. 155 Contractor Cannnie Engineer-s. Aaarws , Fnglewond, ;f0 80111 License No. N/A Phony - 47 'TYPE OF WELL/PUMP: NEW WELL G➢ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL MILEPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom N Manteca Dia. of Well Excavation 6 in Dia. of Well Casing; 2 in- L. Domestic/Private ® Gravel Pack ❑ Tracy Type of Casing PVC, SCH 40 Specifications ❑ Public ®��Oth�er 11 Delta Depth of Grout Seal 6 ft Type of Grout Cpmpnt ❑ Irrigation 3ZHpprox. Depth ❑ Eastern Surface Seal Installed by Hand Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 509 RPntnnitP and rpmpnt Depth ADDrOx,35 ft. Filler Material (Below 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No=depth -, if public se. ava Installation will s Residence_ Commercial_ Other Number of living units: Number of bedrooms `Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ndation Property Line ,LEACHING LINE 1 ❑ No. & Length of li length/size FILTER BED ❑ Distanc eafett:' Well Foundation. Pr Line - SEEPAGE PITS ❑ Depth Size Number .SUM ❑ Distance to nearest: Well Foundation Property Line ISPOSAL 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's compensation laws of California."Contractor's hiring or subcontracting 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 of California." The appl' ant m at All for II equir��{,d�i (3Qecdons. Complete drawing on reverse side. Signed ` �'FC� •1 t Title: Date: Q FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection b� v Date Final Inspection by Date Additional Comments: A/ i -��Q�G2 t G��L�Z44y .p ElStk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 04 ❑ Tracy 035-6385 ' .Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r' FEE AMOUNT DUE AMOUNT REMITTED CK RECEO/ED BV _. DATE PERMIT N0.' INFO CASH . EH 13211REV.t/w sl EH 14-26