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4 ' APPLICATION FOR PERMIT ^:C < SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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 osquin Local Health District. 'cf s2?3 b— \ q 1-1� Job Address 5119 A R C H E R D A L E R D. City LINDEN Lot Size PM_ .1 — Owner's Name CHERRY STROUD _ _ Address 5119 ARCHERDALE RD Phone 887-3393 Contractor's Name H E N N I N G S BROS. D R I L LLicense No. 290813 Phone 4 — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100'— SEWER LINES 100 ' + DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom i_l Manteca Dia. of Well Excavation Dia. of Well Casing 611 CQ Domestic/Private "Gravel Pack ❑ Tracy Type of Casing P V C Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 5 0 1 Type of Grout B E N T O N ITE _ ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by H E N N I N G S BROS. Repair Work Done ❑ Type of Pump _ H.P. State Work Done_ Well Destruction ❑ Well Diameter t Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet. Installation will serve: Residence_ Commelcial_ Other _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:_ Water table depth SEPTIC TANK [7 Type/Mfg '_—� Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal _______—_. �✓ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cl Depth ---Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and thlat 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:"1 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." The applicant must call for all required inspections. Complete dr wing on reversq aide. 7-22-91 Signed TV, Date: FOR EPA TMENT USE ONLY rn� Applicat' ccepted by 1-1 Date 1 Area Pi or faro spection by"- �� - Date Final Inspection by— Date Additional menta: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82 04 ❑ Tracy 6W6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'N0.CA ��✓T"—f C� 5?91s� Nd t�',P t . a EN 13211REV.10/631 _ — +J EN 1446 q