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rr APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209} 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 1 'i 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 welUpump and the Rules and Regulations of the San Joaquin l Local Health District.i I Job Address -1930-6 GA71"i TT Pix] City Sri OTS TO ?Lor size 3 o C PM ' J Owner's Name jhry , .�'L-ZIGET r Address SAM Phone �-6 -'497 1 ContractorKETTR GROSS Address PO BOX 1 V3 License No.177�35 `Phone 33, -4725 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 13r DESTRUCTION l'ak' PUMP INSTALLATION iJ SYSTEM,REPAIROTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK x.00 SEWER LINES,- 'I'lr —blI PCFSAL FW. t50 PROP. LINE FOUNDATION AGRICULTURE WELL QTHER_WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS - ❑ Industrial ❑ Open Bottom LlManteca Dia. of Well Excavation._ I - Z-''" _ Did. of Well Casing ��Cl� %F 1 Domestic/Private 6 Gravel Pack ❑ Tracy Type of Casing 170 Specifications M Public ❑ Other ❑ Delta .,Depth of Grout Seal 0 r 1 Type of Grout CCM mt _- I I Irrigation .-Approx'Depth I I Eastern J Surface Seal-Installed by, c�n1raC�C1r _ I Repair Work Done ❑ Type of Pump S.1113 H.P. �7 r` ' State Work Done Iva HADd--- Wel! Destruction ❑ Well Diameter Sealing Material (top 501 r ~� I I Depth Filler Material {Below 50'f -- TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is I - - available within 200 feet.) i Installation will serve: Residence I Commercial_ Other I Number of living units: Number of bedrooms 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 tines Total length/size Y FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 d 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 required inspections. Complete drawing on reverse side. 1 Signed X,� i �/,b•� Title: 011Mi'R Date: 8 N 89 FOR DEPARTMENT USE ONLY Application Accepted by Date ` Area �. Date r p Y ' Date U Pit or Grout Inspection by tool Ins action b rAdditional 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. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 9 Q p +.EH13-24iREV.1 5) �,05 .OS �� Q 0- 91 )-).Z7-. EH 14-26