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4` APPLICATION FOR PERMIT,' I I/�n SAN JOAQUIN LOCAL HEALTH DISTRICT R I 1601 E. HAZELTON AVE., STOCKTON,;CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED (Complete in Tripiicate) - Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wok herein described,This a 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 J Local Health District. pplication n . Joaquin Job Address �LEVENTN STRCF city. "rR AC Lot Size_100 X 94 _ PM Owner's Name KAYD OIL C�}Mp�Jy Address • .BOX 1 Q r LoDr t 52 Phone 201/369— 36$= { Contractor./461 4 ECOER DRfLLIR Address28 STae>~cTeN� � 9�xes~ I TYPE OF WELL/PUMP: NEW WELL License No.� Z Phone PUMP INSTALLATION WELL REPLACEMENT ❑ DESTRUCTION ❑ ❑ � ` DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR Li OTHER Li _ SEWER LINES �� DISPOSAL FLD. s i FOUNDATION �__ gGRICULTURE WELL — PROP' LINE ,INTENDED USE _ "' OTHER WELL PITS/SUMPS p —TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom F ❑ Manteca I Dia. of Well Excavation , zi ❑ Domestic/Private - IJ Gravel Pack �j Trac � Dia. of Well Casing Z Tracy. Type of Casing . 'Pvblie Y�[Dhi�r?Yiwtq ❑ Other « El Delta Specifications $ yy,�]�/ 11 Irrigation t ,J 30f Depth of Grout Seal4 O� { -�Approx. Depth ❑ Eastern Repair Work Done Surface Seal Installed by ❑ Type of Grout Ce e Type of Pump ~~ H.P. State Work Done Well Destruction' ❑ cALr�rdi w.,e Well Diameter Sealing Materia! (top 50') DepthFilter M z �. aterial (Below 50') TYPE OF SEPTIC WORK: NEW.INSTALLAI ION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public ti' �^ P sower is Installation will serve:-Residence_ Commercial � � t available within 200 feet.) Number of livingunits: Other t Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth e PKG. TREATMENT PLT. F] Capacity _ No. Compartments Method of Disposal Distance to nearest:, Well I Foundationt �.. —� Property Line LEACHING LINE ❑ No. & Length of lines - `` -�� ► FILTER BED ❑ Distance to nearest: Well Total length/size Foundation �^ ,Property Line SEEPAGE PITS + ❑ Depth Size SUMPS Number 1 D Distance to nearest: Wep,�_y - DISPOSAL PONDS ❑ Foundation Property Line_ 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 rules and regulations of the San Joaquin Local Health District. Home owner.or licensed agent's signature certifies the following., . and employ any person in such manner as to become subject to workman's compensation laews of California."rformance Cont actowork for r which this or ub-contrraacttinglsignature certifies the following: 'I certify that in the performance of the work for which this permit is issued,I shall em to l not tion laws of California." p y persons subject to workman's compensa- The applicant ust call for all required inspections. Complete drawing on reverse side.- Spe Signed — dt'auslYs' 3 te(1S Title: '�-f : Date: 9 FDEPARTMENT USE ONLY i� + Application Accepted by. - z - E �� Date Area Pit r Grout Inspection by. Date Final Inspection by Additional Comments, Date z ❑ Stk '46&6781 ' r ❑ Lodi 389-3627 ❑ Ma eco 823 7104 11 Tracy. 835-6385 _ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE i INFO AMOUNT REMITTED CK BY CASH DATE PEgMIT`ND. +EH 13.24{REV.1/051 �' -•-/•� /� EH 14.28