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V II APPLICATION FOR PERMIT ti i Y ' SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA rC� I Telephone (209) 466-6781 8,4/V J ] PERMIT EXPIRES 1 YEAR FROM DATE ISSUEP� L�,QQU`N (Complete in Triplicate) �IS q � I Ir x; r,r��1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des a pplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and-the Ryles and Regulations of the San Joaquin Local Health District. .a: "►i'' a�_ ' - Job Address 28142 Kassan',Rd�' 800 ft.N.of LinneRd.&ty Ttac 2 ' Lot Size PM i Owner's Name Ronald FG Silva Address 21365 Mission Blvd. Phone Contractor owner Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - �. - --,� --- ---FOUNDATION"- —� �'-°'-""AGRICULTURE WELL .!- OTHER-HELL— �-PITSYSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth 1-1Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material hop 501 Depth Filler Material (Below 501 ? TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION KiNo septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence_ Commercial_F Other Number of living units:' Number of bedrooms ~ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg nnknnwn " ;!Capacity unknown No. Compartments PKG. TREATMENT PLT. ❑ '\ 7 Method of Disposal Distance to nearest: Well t- Foundation "Property Line LEACHING LINE ❑ No. & Length of lines unkmwwn Total length/size FILTER BED ❑ Distance to nearest: Well + Foundation ` ' Property Line SEEPAGE PITS ❑ Depth Size Number _..SUMPS •©.pistance..to-nearest:-— Well -Foundation==' _ �"--�Rroperty-L-ine '�� DISPOSAL PONDS ❑ r 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.. A Home owner or licensed agents 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:,; ify that in the performance of a ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor The applicant m call for al squire spections. mp a drawing on reverse side. r Signed Title: owned' Date: 226/85 FOR DEPARTMENT USE ONLY Application Accepted by Date' Z Area—Q 2 t Pit or Grout Inspection by rs Date Final Inspection by jIr59d- Tnscf7w c �c;(eo! lir sr Fs r� �loi�n �, `2 9p �4u x/11 T1 +4 i�faLcS 'e«V:7"3 .� �7`fo� i Ad6iti nal Comm ts: ❑ Stk 466-6781 z ❑ Lodi 369-3621 ❑ Manfew 823-7104 17,-Tracy 835-6385f�72G Applicant= Return all copies to: Environmental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 P ,c{6✓e;0 . IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH REC=IVED BY DATE PERMIT'NO. +EH 13-24(R EV.i/s 5) Q, Ll Com— / 7/9c5 EH 14-26 ,.. - 3'zflga