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-� -APPLICATION FOR PERMIT pr -or _ 5AN JOAQUIN LOCAL•HEALTH DISTRICT 7 t'`� •'4'A-r; 1601 E. HAZEL T ON AVE., STOCKTON, CA` �1 rir _..�'` ,,rra- �'� .� W4, Telephone (209) 466-6781 f L vq DATE ISSUED PERMIT PERMIT EXPIRES 1 YEAR FROM �. (Complete in Triplicate) p p _7e..a 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaqui. Local Health District. Job Address_�=11711 E. Eight Mile Rd.e., Stockton_city Lot Size PM Robert Cademartori 13881 E. Eight Mile Rd. , Linden Owner's Name Address one Contractop-ur -i. -Drillers P. O. Box 64-,Lind e Brise No. 377923 Phone 8'87-3554 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEME-NT ❑ DESTRUCTION LX ` PUMP INSTALLATION X, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Ft_D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION'S` © Industrial X Open Bottom LJ Manteca Dia. of Well Excavation 1Z,-"—Pia. of Well Casing 8,r Domestic/Private ❑ Gravel Pack LITracy Type of Casing st-eel Specifications $-8 I � F7Public ( Other C1 Delta Depth of Grout Seal 50 Type of Grout Cent I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 17 Type of Pump Sub H.P. 11 hp State Work Done drlJ _!--„new wQ l Well Destruction SIN Well Diameter 8!r Sealing Material (top 508r _tivw pumps 'abandon Old well.. i Depth .Z 9 --Filler Material (Below 50'l .4 TYPE OF SEPTIC WORK: NEW,INSTALLATION (1 REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewex._is ` �tr available within 200 feet.l —, insta�ion will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:' Water table depth " I SEPTIC TANK ❑ Type/Mfg C\pacity No.Compartments - ,-•w P,KG-TREATMENT PLT. ❑ Method'. ethod of Disposal I Distance to nearest: Well Foundation Property Line "r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED- ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Size Number - y SUMPS Ll* Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ _ I hereby certify that I have prepared this application and that the work wi be done in accordance with San Joaquin county ordinances, state la+ks f rules and regulations of the San Joaquin Local Health Di§trict. 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 r employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signau 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 coritpen; i tion laws of California." E �, •�-�A The applicant ust call for all.ce wired inspections. Complete drawing an reverse side. k Signed Title: President Date: 7/31/139' k FOR DEPARTMENT USE ONLY Application Accepted by Date_LZf Area y Pit Grout nspection by fJ� Date `:f7�'nFinal Inpspection b �Y/�J"t>�r Dat 2-. Additional Comments: c -f v �� c. 1/ yr C o_r o_!'..pf ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health r it Service 1601 E. Heze on Ave„ P.O. Box 2009, Stk., CA 952 i ;J9 J2 j INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' .*.EH t3 EH 11-28 -21(REV.titt5l n- {