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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I ` 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 Agules and Regulations of the San Joaquin 1 Local_Health.District. t 24?—0 QO— d 2 1.. .3cFt Job Address T- nsl'esland;v Mile 28.5 Stockton City Stockton Lot Size 40 Ac.+ PM Bk 129,p.090 i Parcel 2 Deep Water Channel i St. Francis Yacht Club On the Marina, San Francisca Phone 415 563-6363 Owner's Name 1 nAddress P,d,l3o,r 333`J 5'�hf /Pnf94123p Kirkwood.-B1 Inc. 18806;A Z r Phone (707) 585-3762 ) Contractor's Name �'' License No. ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION )Kl REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-Z— Commercial— Other Recreational/Resort Number of living units: 11 Number of bedrooms 22+ Occasional Occupancy Character of soil to a depth of 3 feet: Peat Water table depth 4 ft. variable SEPTIC TANK ElType/Mfg Capacity No. ;Compartmentsto PKG. TREATMENT PLT. El Method of Disposal S ra Irri at Distance to nearest: Well 470 ft. Foundation 300 Property Line 630 ft. Aerated Tmt. Lagoons with spray irrigation disposal LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line * See specifications for Construction of Wastewater Management Facilities for 'I SEEPAGE PITS C1 Depth 9 ft. Size 85 ft. Dia. Number 2 Tinsley Isla d k SUMPS ❑ Distance to nearest: Well 600 ft. Foundation 330 ft. Property Line 430 ft. 4/85 on file DISPOSAL PONDS * 51 Aerated Treatment Lagoons I hereby certify that 1 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 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." (site plan attached) ia, The applicant must call for all requi ed ins tions. Complete drawing on reverse side. Signed Title: � ! /�'/.A/✓ _l Date: /O ' 3'V �J FOR DEPARTMENT USE ONLY Application Accepted byDate5 �' Area Pit or Grout Inspection by Date Final Inspection by _ Date C3 � l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82:3-7104 ❑ 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 CK RECEIVED BY DATE PERMIT'NO. INFO + EH 13241REV.10/831 �s-`3RO cu,max