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ao APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address 8740 North Helen city Stkn Lot Size 3 acres PM Owner's Name Kurt Cooper Address 1519 Black Oak Dive Phone478-82.138 Clark Well 371.560 462--7676 Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL,,t7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALL{jTIg,g)7 SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC.TANK ]],,�� SEWER LINES DISPOSAL FLD. PROP. LINE 4A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS;:,. INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5� El Industrial l a1 Open Bottom ❑ Manteca Dia. of Well Excavation r� Dia.of Well Casjn 6 X® Domestic/Privat� Gravel Pack ❑ Tracy Type of Casing Steel Specifications 1 ❑ Public C1 Other C1 Delta Depth of Grout Seal 50 Type of Grout ( 9 sack .❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by Clark Repair Work Done ❑ Type of Pump Sub H.P. 2 State Work Done' install Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS. E Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 cert at 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 s c r I r it n ti . C plete drawing on reverse side. Signed Title: VP Date: 19 Feb 1988 FOR DEPAWMENT USE ONLY Application Accepted by Date / Area Q� Pit or Grout Inspection by Date T Final Inspection b �/ Date's i�l Additional Comments: �L 4 ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Ment& 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 INFO AMOUNT DUE A NT EMITTED CK*CASH RECEIVED BY DATE PERMIT + EH 13-24/REV.10!831 - EH 1426