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�. .. r - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Y 00 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) /30 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Thisappfication is made in compliance with San Joaquin County Ordinance It 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. S.E.C. Hammer 'Lane and Rolman Road City Stockton Lot Size 27.440 sq. ftpM Job Address Owner's Name Barghausen Consulting Address 18215 72nd Avenue South Phone 2206) 251-6222 Kent, Washington 98032 Contractor Ba Area Ex /oration Address P.O. Box 157, Suisun CA License No, 5 ZZ.t26 _Phone (707)864-2I 1 TYPE OF WELL/PUMP: NEW WELL ❑ ? WELL REPLACEMENT El DESTRUCTION 11 ! — - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES >100 ft. DISPOSAL FLD. PROP. LINE .FOUNDATION AGRICULTURE WELL.-- - OTHER WELL .- rPkTS/.SUMPS, N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca N/A Dia. of Well Excavation6 i nr_h Dia. of Well Casing ❑ Domestic/Private ® Gravel Pack ❑ Tracy Type of Casing PVC Specifications F 1 Delta Depth of Grout Seal ? Type of Grout M Public 1I Other mp I I Irrigation __Approx. Depth l I Eastern Surface Seal Installed by Bay Area Exploration _ � -- - p. ' Repair Work Done [71Type of Pump — H.P, --- State Work Done _-- `4 Sealing Material (top 50'1 N/A Wel Destructiori. El Well Diameter �]nG�l.-- 9 Depth Filler Material (Below 50') IN TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION I i alvailabPeiwithin 200 feetstemit'ed if public sewer is r Installation will serve: Residence 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 .41 PKG. TREATMENT PLT. ❑ f Method of Disposal w Distance to nearest: Well Foundation Property-Line F LEACHING LINE L1No. & Lengt Total length/size of lines � FILTER BED ❑ Distance•to nearest: Wel Foundation *Property Line f SEEPAGE PITS i I Depth Size Number SUMPS L� 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." 1 1 The applicant m�fallins e s. Completa drawing on reverse side. 4Signed X � - Title: Manager Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �` f Area Pit or Grout Inspection by Date F' 1 Inspect(^^ �y Date' 0 0 � —�--moo Additional Comment . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Re nal ps to ironment I Healt rmit/ arvic 1601 Hazelt�n`AP.O. Bax 2 Sik., C 9 _01 a� �/ •�j � A FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO CASH s +.EH 13-241REV.iiH5Y - EH