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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTOIV AVE., STOCKTON, CA Telephone Q09) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J AN 11 190 (Complete in Triplicate) SAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Locat Health District for a permit to construct and/or install�pJ�jyL C �� LTF1 S r 't S made H compliances with San Joaquin Coun y Ordinance No, 549 for sewage or No. 1862 for welt/ um � �HnorlSl;6&W is Local Health District. Ed 0 F �^, 4_4L �/I' J P P aed Ic u us I�htsrt3 6bff oaquin Job Address 455 East "K" Street , CitVL-4±_lx'0p Lot Size PM Owner's Name San r7oa uin CaGen L ' HOUSton, TX (713) 464-94 1 __-_'AitLed 9432 Old _Katy, Phone Rio Vista, CA (707) 374-2306 contractor H. L. Camp Drill�ir,��r�p, P. O. Box An 6 TYPE OF WELL/PUMP: NEW WELL License No, 0_-121 Phone— NEW — — WELL REPLACEMENT ❑ DESTRUCTION L7 ee eve Opmen PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D (3�taCIlEC1 DISTANCE TO NEAREST: SEPTIC TANK P t n Cfy'90- 9 SEWER LINES DISPOSAL FLD. PRO . LINE FOUNDATION AGRICULTURE,WELL OTHER WELL X _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIICCA-T�IIOONS ICMnd+astrial ❑ Open Bottom CJ Manteca Dia. of Well Excavations 7 rr 11 Domestic/Private L} Gravel Pack y T LT&C 2 3# Dia. of Well Casing ❑ Trac Type of Casing- K_5 5 N_8 Q I"I Public Other Specifications 80- XX ❑ Delta Depth of Grout Seal SUrfaeiTD CIaSS G i I hrigation 5300 Approx. Depth I ! Eastern _ Type of Grout _Ce OTlt Surface Seal Installed by Contractor Repair Work Done ❑ Type of Pump _ _ Well Destruction ❑ Well Diameter H.P. State Work Done Sealing Materia) )tap 50'I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I ] RLPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial Other available within 200 feet.) Number of living units: Number of bedrooms G Character Of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity Water table depth PKG. TREATMENT PLT. ❑ No. Compartments I r Distance; to nearest: Well Foundation Method of Disposal ' Property Line LEACHING LINE L3 No. & Length of lines ~ FILTER BED ❑ DiTotal length/size Distance to nearest: Well Foundation Property Line [' SEEPAGE PITS i I Depthf Size Number SUMPS LI Distance to nearest. Well � LL DISPOSAL PONDS I I Foundation Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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: "1 certify that in the performance of the work for which this permit is issued, I shall C employ tion laws of California." p Y Persons subject to workman's compensa The al ust call or re inspections. Co a drawing on reverse side. Signed x_ Environmental Engine s- Ti►a FOR DEPARTMENT USE ONLY Application Accepted by j,v } Date Area 1/L,J[' Pit Or Grout Inspection by Date Final Inspection by Date Additional Comments: '�� / �4� �� Q / E l Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 v' Applicant - Return all copies to: Environmental Health Permit/Sarvices 1601 Ea azar on A3 Ave., Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO IREV-��n5� ter.