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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECElv1=D Telephone (209) 466-6781 19 198`3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work i' application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an eg Iations of the San Joaquin Local Health District. Job Address 27300 N.Sowels std. city AeamPo Lot Size 10ac, PM 954240 Owner's Name Bob Kent Address P.O. BOX 1391 Lodi,Ca. Phone 74.5-4R6 5 Gal t,,Ca.95632 Contractor Woods Well DrlAingddress 11944 Simmerhorn License No. 282866 Phone — TYPE OF WELL/PUMP: NEW WELL 4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION= SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150 t SEWER LINES 150 DISPOSAL FLD. 1 5n PROP. LINE h(1 tt FOUNDATION 50 t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 8" �1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal 50 , Type of Grout sandceaett I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by WoodS Repair Work Done ❑ Type of Pump Submersi� e 3hp State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is C1 available within 200 feet.) 7J Installation will serve: Residence Commercial Other "-3 Number of living units: Number of bedrooms ()J 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 BED O Distance to nearest: Well _ Foundation Property Line V SEEPAGE PITS I I Depth Size Number Q SUMPS Ll 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." 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." The applicant must call for all re ire d ins tions. Complete drawing on reverse side. Signed , ,�.� -1 Title: Contractor Date: 8/19/88 /i FO¢iDEPARTMENT USE ONLY Application Accepted by / Date ) Area Pit or Grout Inspection by Date /2 inal Inspection by Date Additional Comments:/�"� � .% T �✓�� rvs rzi ❑ Stk 466-6781 ❑ L�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 CK }i RECEIVED BY DATE PERMIT NO. INFO . EH 13-24(REV.1,Hal lf`>• ?"� ( �. L.'L.%, "'�i"' EH 1428 � r�'-