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APPLICATION FOR PERMIT ��1j1V[ED 4 SAN JOAQUIN LOCAL HEALTH DISTRICT R�GIV t 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 'PERMIT EXPIRES T YEAR FROM DATE ISSUED HEA111 i (Complete in Triplicate) Application Application is he+ehy made to the San Joaquin Local Health District for a permit�to construct and/or install the work herein de c e s application is wor No. 1862 for we111pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for seage Local HealthDistrict c� City Stockton Lot Size 7,000 f t- PM t+"irEast Tremont Street Job Addre .Toe A. �')•.att05 Address 724 N 1st San .Tose, CA 95100 Phone(408) 295-2442 Owner's Name Phone 415 685-6 Contractor 13 Kvilhaiigh Well Dri.11i ress 1676 Risdon Rd. , ConcordLicense No.482390 ( ) TYPE OF LL/ P. . , *NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 monitoring well SYSTEM REPAIR ❑ OTHER p 4 PUMP INSTALLATION ❑ 35-2004 DISPOSAL FLD. — PROP. LINE 6 DISTANCE TO NEAREST: SEPTIC TANK 73-1651 SEWER LINES � 22_1534 `1) I F 77'1271 AGRICULTURE WELL 1 mi OTHER WELL104-1444PITS/SUMPS � 9, FOUNDATION -v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS es Dia. of Well Casing � I ❑ Open Bottom ❑ Manteca f Dia. of Well Excavation © Industrial PVC seh 40 Specifications ij ❑ Domestic/Private :i Gravel Pack r ❑ Tracy Type of Casing f Grout cement C7 Delta Depth of Grout Seal 29 ft Type o ❑ Public ❑ Other „. driller. I 1 Irrigation ---APProx. Depth IKI Eastern Surface Seal Installed by none , of Pum none H•f. none State Work Done_— Repair Work Done Ll Type p none �j Well Destruction ❑ Well Diameter 11 inches Sealing Material top 501 " Depth 60 f t Filler Material (Below 501 none 1 TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIRIAODITION l I DESTRUCTION l i eNailabpelwithin 200 feet1t�ed if public sewer is Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity �. y Method of Disposal ' PKG. TREATMENT PLT. ❑ s Property Line Distance to nearest: ? Wel! foundation Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED El Distance to nearest: Well Foundation lSize _ Number II SEEPAGE PITS I Depth Property Line SUMPS L-1Distanceto nearest: Well Foundation 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 I rules and regulations of the San Joaquin Local Health District. t 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- t tion laws of California." 1' The applicangnm call for all required i spections. Complete drawing on reverse side. Signed X Title: Date: r FOR DEPARTMENT USE ONLY Date .Area \' Application Accepted by 1! k1L Pit or Grout Inspection by Date 1 Final Inspection by Date GG O t r l Additional Comments: ID Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AIyIOUNt DUE AMOUNT REMITTED CASH RECEIVED BY DATE p pPEpRMIT NO. INFO d F r + EH 13.24 IREV. i n 5) I I EH 14-26 - __,