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` APPLICATION FOR PERMIT Well ^plugging �. " SAN JOAQUIN LOCAL HEALTH DISTRICT #11 , 12, 13,' 8, 1 and 1601 E. HAZELTON AVE., STOCKTON, CA l red r i 1 ] Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED !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. 900 S. Cherokee Lane i Job Address City Lod 1 Lot Size PM i Owner's Name __Kayo 01 I Company Address900 S. Cherokee Lane LodiCA Phone 20 �3/368-2131 Stockton CA 95240 Contractor J• H• K l e i n fe l de r Address 282$ E. Myrtle St.., License No.467252(C-57)hone 1209/948-134 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE T DESTRUCTION IN11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ M DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 251 DISPOSAL FLD. NA PROP. LINE . t FOUNDATION Z F AGRICULTURE WELL NA OTHER WELL..,]_ PITS/SUMPS XA_ j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� J Ck Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 211 ❑ Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing PVC Specifications I� FI Public Cl Other Cl Delta Depth of Grout Seal tO Surface Type of Grout Benton 1 te- _ I Irrigation -5-5--Approx. Depth I 1 Eastern Surface Seal Installed by Contractor Cement Repair Work Done E Type of Pump none H.P, State Work Done_ jM Well Destruction Id Well Diameter 211 Sealing Material {top 501 Benton i te-Cement Depth 55 t, Filler Material (Below 50') BentOn i te-Cement IM TYPE OF SEPTIC WORK; NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is I ` available within 200 feet.) i Installation will serve: Residence— Commercial_ Other T 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 �M 4 PKG, TREATMENT PLT, ❑ Method of Disposal M Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line r` SEEPAGE PITS I I Depth Size Number iP t r SUMPS Ll Distance to nearest: Well Foundation —_ Property Line DISPOSAL PONDS 0 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 f 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 of California." I , The applicant must call for all required inspections. Complete drawing on reverse side. Signed x . 5, 19$7te: gineer ; Date: FOR DEPARTMENTU�E NL Application Accepted by Date Area Pit or Grout Inspection b Date Final Inspection by 'bate Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i 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 RECEIVED BY Dg7E kPERMIT"N' O.INFO GASHa+ EH 13-24(REV.i/n 51 ApR _ ��EN 1t-2B f�^� 'rOIK.. ' F'/�7J�'r / i