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r - k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED i I (Complete in Triplicate) t-.,)0\_0 i :.� *TapplQfion ;Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describeis X I 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 Joaquiri� Local Health District. fl Job Address 9161 South Gertrude city Stockton Lot size PM A.R. Kramer 916 South Gertrude 209-463-5513 Owner's Name y Address, Phone Contractor Williams Pl'Lbing Address 2360 N. Wilson Way License No. 289293 Phone 209-466-400 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ i OTHER F1 j DISTANCE TO NEAREST: SEPITIC 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 1:7 Manteca Dia- of Well Excavation j Dia: of Well Casing -r� . 11 Domestic%Pri;a[6`` ❑ Gravel Pack_'— 1:1 Tracy Type of Casing f Specifications" a I'1 Public n Other— Ll Delta Depth of Grout Seal Type of Grout 9 ! i I Irrigation { 1I14pprox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Typelkof Pump H,P. State Wo r Done Well Destruction, µ❑ Well Diameter Sealing Material (top 50'1 Depth4 Filler Material (Below 50'1 TYPE OF SEPTIC WORK: 'NEW INSTALLATION [�l- REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is . vailable within 200 feet ) \ ,Installation will serve: Residence_ Commercial� Other e Number of living units: Ali Number of bedrooms ) Character of'soil to a depth of.3 feet: Water table depth T SEPTIC TANK, ❑ .Type/Mfg �.. Capacity" No. Compartments a PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well—f "'"'"'"Foundation Property Line LEACHING LINE' 17.3 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel] Foundation Property Line SEEPAGE PITS I I Depth Size Number f SUMPS Cl Distance to nearest: Well Foundation Property Line 1 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 SanlJoaquin Local Health District. Home owner or licensed agent's Isignature 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 h certifies the following: "I certify tat in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compansa- # tion laws of California." IIG , The applicant u call for all rep SD actions Complete drawing on re 'de. ` Signed X Title: 'G �+ -- Date: ` F t DEPARTMENT USE ONLY Application Accepted by L" Date B—p� ^'� Area Pit or Grout Inspection by !p� Date Final Inspection by Date Additional Comments: �p ❑ Stk 466-6781 ❑ Lodi NJ369-3621 C7 Manteca 823-7104 ❑ Tracy 835-6385 ! Applicant - Return all copies to: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA'95201 ` FEE AMOUNTDUE AMOUNT REMITTED CK ! INFO 6 CASH RECEIVED BY DATE PERMIT'NO. +.EH 3-24{,REV.It ha ' �EH 14-26 ,v