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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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 4.4.3 4 Ho l 1- Rd City Lot Size . +40 a r r c-s c PM Owner'sNamponrad Silva Address 3211 S . Holt Rd Phone 465 1834 Contractor Clark Well Address 2024 E. Charter Way License No. 3 71 560 Phone_462-7676 TYPE OF WELL/PUMP: NEW WELL F2 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 QO r„ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 2 rr Dia. of Well Casing 6 5 18" K4Domestic/Private XkGravel Pack ❑ Tracy Type of Casing P11 r, Specifications CL 1 25 ('l Public f_1 Other *kDelta Depth of Grout Seal r T eo" rou _ 6 ype o rant I 1 Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION (.1 REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feed Installation will serve: Residence__ Commercial_ Other Lo 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 SEEPAGE PITS ( I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS ❑ r 1 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 R 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 sub-contracting signature I 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 applicca f r I 're uired i pections. Complete drawingWZR// Signedr9Title: Date:2 7 9 F. ENT USE ONLY Q Application Accepted by Date Z ` Area Pit or Grout Inspection by to ��_GFinal Inspection by Date r Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' a.EH 13-241REV.r/e5) Q� LtiJV Err 14-2e