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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. APN 01 3 080 �"-Z� Job'Address 1100 W. Petier Rei _„_._-____ City —4ai Lot Size acres— PM Owner's Name Mike Kennedy Address 2960 Ailing Circle Phone I - Contractor Clark Well Address 2024 E. Charter License No.371 560 Phone-.462-7676 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 n n�� SEWER LINES DISPOSAL FLD. PROP. LINE 2-4 0 ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS --1-50 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 2 rr Dia. of Well Casing rr R Domestic/Private k--kGravel Pack ❑ Tracy Type of Casing Stee-1'.i. Specifications #1'2 Li Public f] Other ❑ Delta Depth of Grout Seal r Type of Grout-9_cnck I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Clark c Repair Work Done ❑ Type of Pump _gj1h H.P. 3, State Work Done —lflStall r i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is b I available within 200 feet.) Installation will serve: Residence_..- Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tabfe depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG: TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WeR Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel] Foundation Property Line i SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 fallowing: " a 'n he perform nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Maws of Calif mi . The applican st I r al equir ti Co to drawing on reverse side. Signed X Title: Date: 9 Dee 1989 jr//RTIMIENT USE ONLY Z— Application}Accepted by Date / J grua Pit F G` wuu)Inspection b�-�- L- ` Date )-Z-1 Final Inspection by N� ��,� Date\�-z �5 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r d . EH 13-21IREV.tiy51 .©� I�� ' EH 1l-2a I 1,