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0 Z: APPLICATION FOR PERMIT M1 ` 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 Joaquin Local Health District. Job Address 6935 EAST TAIL0 City i()f�T _ Lot Size PM r Owner's Name Rrx HI}Y ZA-PA tiA Address S LtT'•DO Phone _5 Contractor KETTK G2 OSS Address _P T' tr 178 License No.3Z7 St 5 Phone 7 `) '— I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IN DESTRUCTION�F] PUMP INSTALLATION 1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _�1 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial E) Open Bottom L1 Manteca Ria. of Well Excagjtoe Dia. of Well Casing 9 Domestic/Private ©i Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public i.1 Other ❑ Delta Depth of Grout Seal ! Type of Grout r �z? 1 1 Irfigation 2'__41Approx. Depth l I Eastern " t Surface Seal Installed by r :;G3 Repair Work Done ❑ Type of Pump STB H.P. State Work Done f'y4 ?T'bT rte- Well Destruction ❑ Well Diameter T Sealing Material Itop 50'1 Depth Filler Material iBelow 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION f I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) n Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms t �l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size r _ Number SUMPS L71 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 of 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 California." The applicant must call Oor all required inspections. Complete drawing on reverse side. o1111TE 8.7:483 Signed X� r ifa'i..� ____- _ Title: Data: �()R DEPARTMENT USE ONLY Application Accepted by Date � � i �n! Area Pito rout nspection by ate Final Inspection by Date 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 AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. INFO 09 + EH 13-24 tREV.i/a 5) A p ! EH 14-26 9q IA