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I READY FOR INSPECTION p' APPLICATION FOR PERMIT � APR I i OEM SAN JCAgUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. _Lk b 4 Telephone (209) 466-6781 S' j0AQUh-4 LOCAL DATE ISSUED IJ ®iSMCT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jkk , (Complete in Triplicate) f Application is hereby made to the San Joaquin Local Health=Ois ict-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. Job Address 24651 N.: Jack Tone Rd. . Subdivision Name Owner's Name Kenneth Burger Address 24651 N. Jack Tone .Rd . Phone Contractor's Name Goehrin . Pum .License No. 309031 Phone 27-55 48 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION _ - PUMP INSTALLATION �` SYSTEM REPAIR OTHER ❑ ' 1 DISTANCE TO NEAREST: SEPTIC" TANK SEWER LINES DISPOSAL FLD. PROP. LINE = FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - I INTENDED USE TYPE OF WELL PROBLECAREA CONSTRUCTION SPEC.I-FICATIONS JI ndustrial ❑ 0pen Bottom ❑ Manteca: Dia. of Well Excavation domes_tac/Pr_i-vate �_Grav:elaPack -Tracy`s�...� Dia.=of We31.Casing_- - �, , - -I'- ❑ Public Other - , { C] Delta Type of Casing r _ 't ❑ Irrigation " ` "Approx. Specifications Depth ❑Cathodic Protection 3. ='. Depth of Grout Seal 1-1 Geophysical r Type of Grout +1 LJ Other i r Surfac e.4,S eal Installed by E, Repair Work Done Type of Pump j-31115. Well E� i Stat�W6rk Done 4.Kc .re laced Old UTIIp E Well Destruction ❑ Well Diameter Sealing Material;(top 50')F - Depth Filler Material (,Below 50') kms. ,V TYPE OF SEPTIC WORK: NEW INSTALLATION F1REPAIR/ADDITI.�N Lj�(No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial — Other' Number of'living units: " Number of bedrooms T�— Lot size Character of soil to a depth of 3 feet: # Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ..;I F Capacity Method of Disposal . PKC. TREATMENT PLT. ❑ Type/Mfg � i SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line ! DESTRUCTION *Y - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel'1 Foundation Property Line SEEPAGE PITS Depth Size Number _ --- {` Propert Line SUMPS U,a. Distance.to nearest; Well Foundation Y _Z,.._�D.ISPOSAL.PONDS. ' I hereby certify that I have prepared this application and that the work will he 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 compensation laws of California." Contractor's hi r' sub-contracting signature certifies the following: "I certify that in the performance of the work for which IL this permit i i shall employ persons subject to workman's compensation laws of California." The applica ll r all required inspections. Complete drawing on reverse side. Title: Bk r, Date: 04/1.0/84 Signed x F R DEPARTME USF 0 LYV �- ❑ Stk 466-6781 Application Accepted by r� Lodi 369-3621 !� Additional Comments: Vit or Grout Inspecti�nby Date ❑ Manteca 823-7104 'I Final Inspection by ` ate i / �❑ Tracy 835-6385Applicant - Return all copie : Environmental Healt�ermit/Services 1601 E. Hazelto Ave., P.D. Box 2009, St k., CA 95201 FEE BASEAMOUNT DUE AMOUNT REMITTED RECEIVED BY LATE PERMIT NO. INFO _ kh S.. 10/82 500 EH 13-24 REV. 10/82 y14-26