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Na APPLICATION FOR PERMIT � rkip d" SAN JOAQUIN LOCAL HEALTH DISTRICT •.� 1601 E. HAZELTON AVE., STOCKTON, CA �'�' Telephone (209) 466-6781 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a {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 Ryles and Regulations of the San Joaquin Local Health District. 'ISJob Address ' % itity, Li ndpn Lot Size PM Owner's NameK2n Ford Address 9460 Orford Stockton Phone946-0315 Contractor Address 7487 E Live Oak License No. 391.542 Phone 334-9180 TYPE OF WELL/PUMP: NEW WELL X) WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER I� DISTANCE TO NEAREST: SEPTIC TANK 100+ SEWER LINES DISPOSAL FLD100+`'PROP. LINE2O FOUNDATION 30_ AGRICULTURE WELL OTHER WELL PITS/SUMPS15-a+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial R Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of Well Casing t IX Domestic/Private ❑ Gravel Pack © Tracy Type of Casingg r PC-,1 Specifications 10 ga ❑ Public ❑_Other ❑ Delta Depth of Grout Seal r Type of Grout 9 skJ ❑ Irrigation ___4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑'�-_.Type of Pum - ,r H.P. State Work Done Well Destruction ❑ Well eterSealing M ial-(top 50') 1 pth �ti2_ U _Fifllerplte,ial {Below50') ]v TYPE OF SEPTIC WORK: NEW INSTALLATION fl - REPAIR/ADDITION ❑— DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments :ElPKG. TREATMENT PLTj� ;} .,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 ❑ Depth Size"' Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state,iaws, 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: "I 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 Californi The applicant m all fo ed ins ns. Co plete drawing on reverse side, Signed Title: Date: 6 FOR DEP TMENT USE ONLY `'� !S: Application Accepted by Date Pit o®rout spection by Date r/ Final Inspection by �r D �13 � Additional Comments: f,-, rn ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 "t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. C 5201 C7::; Xt� }� Cr; rd ' INFO FEE K AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE rn.-�'�PERMIT +EH 73-24 iREV. 1/95) EH 4-26 f/a 51 � ��O 1 t