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APPLICATICN FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. SS 3S 1 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete it Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address 8679 E. Kettl.eman Ln. Subdivision Name <br /> Owner's Name Charles Seller Address 8679 E . Kettleman Ln. Phone <br /> Contractor's Name License No. 309001 Phone 727-5548 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 1ZDomesticLPri_vate . _ ❑Gra.vel-,Pack- _-[�]Tr.:acy__ x- _pia.: of_Well--.Easi.n9._ _ <br /> (] Public ❑Other ❑ Delta <br /> irrigation Approx. ❑ Eastern Type of Casing <br /> Depth Specifications <br /> ❑ Cathodic Protection P Depth of Grout Seal r <br /> ❑Geophysical <br /> Other Type of Grout J <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump 112 H.P. Sub. -State, Work—{lone replaced 7 2HP with 1 2HP <br /> Well Destruction ❑ Well Diameter Sealing Material (top",5O') <br /> Pepth Filler Material (Below 50'.) _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RFPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> lristal lati6h-will serve--- Residence . ComiN l"caal c� Other <br /> Number of flying units: Number of b6&ooms�� —' tat size­ <br /> Number <br /> a, : 1 <br /> Character of soil to a depth of 3 feet:.-_. _ Water-t"abl•e.dept# 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line �. <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Cj Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ + <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed gent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, 1 s 1 not employ any person in such manner as to become subject to workmanis compensation laws of California." <br /> Contractor's hir' sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is I all employ persons subject to workman's compensation laws of California." <br /> The applicant 1 11 equired inspections. Complete drawing or reverse side. <br /> Signed x r Title: Bkpr. Date: 04/1.6/85 <br /> FO DEPARTM NT USE ONLY <br /> Application Accepted bAlm"1-47-w Area Stk 466-6781 7`k,r <br /> Additional <Comments: r Lodi 359-3621 <br /> Pit or Grout Inspectiorj by Date ❑ Manteca 823-1104 <br /> Final Inspection by Date i L7 Tracy 835-6385 <br /> Applicant --Return a,b), copies to- Environmental alth Permit/Services 1601 E. Hazelton AV��P.O. Box 2009, Stk., CA 95201 <br /> '1' <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> -INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />