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t 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 (Complete in Triplicate) I ' Apptication 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. Lot of Record Job Address 1 �5H Waina_rr+ ---1�---g Rd, , CitySteekten - Lot SizeX�_�R PM Joe-�Behihbasa same477-3445 Owner's Name Address Phone Contractor-C l a rbc —Wei 1 L Address_2-8.2.4 E. Charter- —License No. Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT I' DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK :75 , SEWER LINES DISPOSAL FLD. PROP. LINE -5Q-L- FOUNDATION AGRICULTURE WELL OTHER WELL--54- PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bott6mit ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 5 8 xFjDomestic/ x�Aj�ravel Pack ❑ Tracy Type of Casing Stela( Specifications # M Public ❑ Other Ll Delta Depth of Grout Seal �11f] Type of Grout -ac-k-. I Irrigation _-.Approx.,Depth l I Eastern Surface Seal Installed by Owner- Repair wnerRepair Work Done ❑ Type of Pump Sub H,P. 1 State Work Done i-- stall P4-Tlwrier Well Destruction ❑ Well Diameter Sealing Material (top 501 to H-ok-up.-. Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 i SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 Dstrict. 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: " at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cali rni The applican st c for I r red ' tions. Co late drawing on reverse side. Signed Title:VP Clark Wel IncDate: 9 Aucf 198,.9 _ FOR DEPARTMENT USE ONLY i Application Accepted by Date =RS Area r Pit or Grout Inspectionby ' Date U Final Inspection by Date Additional Comments - QO ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 835-6385 j Applicant - Return all copies to: Environmentat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952091 FEE 1` 1 INFO AMOUNT DUE r AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMIT NO. a.EH 13-24MEV.1/851 �� I EH 14-26 f ...1