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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iComplete 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 Laval Health District. Now Petersburg Job Address 21969 E•' Third city Linden Lot Size 1.5 Ac.— PM l Owner's Name Ken Ford "0' Address 7460 E. Orford Stockton $$Phone 6"`0 Contractor's Name 'Thaye;r We'11 Drf11il'119,nse No. 391542,. Phone TYPE OF WELL/PUMP: NEW WELL.1 WELL REPLACEMENT ❑ DESTRUCTIONNS iia `- `=-A ",:I- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES DISPOSAL FLD. PROP. LINE 7 t {� FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS -1509 INTENDED USE ; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom 0 ❑ Manteca Dia. of Well Excavation IM _? Dia. of Well Casing *9 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_StSel Specifications 12 � ❑ Public ,Q.9ther j ,,,,,,,,,.E1.,Del1a- Depth of_Grout_Seal_ NF1 f _,.T-ype-of.,.Grout9 sk' ❑ Irrigation Approx. Depth ❑ Eastern , Y Surface Seal Installed bySteve thayer Repair Work Done ❑ Type of Pump" """ '"""H-. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') �� 3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADOTMN ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of-bed ra ms=-- N; Character of soil to a depth of 3 feet: .� Water table depth a SEPTIC TANK ❑ =Type/Mfg=`1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �- ` Distance to nearest: Well ''" Foundation Property Line E LEACHING LINE ❑ No. & Leng$i of lines i - - Tota! length/size FILTER BED ;7_ ❑ }Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ .Depth Size Number _ SUMPS ❑ -Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �-- 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 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."Contractors 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 California." t The applicant m �1-forall�reqo'u'red'in cit omple"te drawing on revs Signed Title:_ +� Date: FOR DEPARTMENT USE ONLY Application Accepted I ek� Date r Area Pit or Grout Inspection by ate G. Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 REMITTEDCK# RECEIVED BY DATE PERMITi190,, . IN EO_ :. _ —CASH_ _ v + EH 13-24IREv.10/63r �°o r✓ � �.�` � = �-! S cQS-2.iod EH 14-26