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w t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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 instaii 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 5835 E. CHEROKEE ROAD City STOCKTON Lot Size PM Owner's Name BEL AIRE MOBILE ESTATE- Address P.O. BOX 99 , STONY FORD, CA 959779na 931-2010 Contractor NOACK PUMP CO. Address 4500 E. FREMONT ST, _STOKJPN No. 504513 Phone 948-8817 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE4ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IN PUMP REPAIR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ITYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ❑ Industrial -❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , [X Domestic/Private r`O Gravel!Pack ; ❑,Tracy t" "_ Type of Casing Specifications ['l Public ;,❑ Other Fl Delta ._._ Depth of Grout Seal �Type of Grout � I I Irrigation '1._..Approx. Depth l I Eastern Surface Seal Installed byA Repair Work Done H.Type of Pump SU �+B lER$1BLk,p. 7-1/2 HP State Work Done`,F"LIFT PUMP, REPLACE � f Well Destruction ❑ s Well Diameter Sealing Material (top 50') BLEEDER VALVE AND SET PUM ACK. Depth Filler Material [Below 501 W } TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/.ADDITION I i. DESTRUCTION l I INo septic system permitted if public sewer is (� q available within 200 feet) � Installation will serve: {`Relsidence_Commercial_.w Other Number of living units: r Number'of bedrooms f r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ .T_ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation - Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number } SUMPS 0 Distance to nearest: Well Foundation Property Line 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 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 certifies the following: "I certify that in the perforrinance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must 11 for all rpquc ions. plete drawing on reverse side. -} Title: - SALES/SERVICE Signed X Date: �d FOR DEPARTMENT USE ONLY Application Accepted by � o 2—IS Date Area . Pit or Grout Inspection by Date T __ Final Inspection by Date1 �Q Additional Comments: ❑ Stk. 466-6781 ❑ 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 AMOUNT DUE AMOUNT RE141YTTED CK 9 RECEIVED BY DATE PERMIT'NO, INFO CASH r.EH 13-24(REV.1/n5) - � S• / - 9V-a3 EH 14-26