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! ' gid APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �- S I 1601 E. HAZELTON AVE., STOCKTON, CA o W e fly Telephone (209) 466-6781 PERMIT EXPIRES 7'YEAR FROM DATE ISSUED I (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, Job Address 3906 E• r r3]17l St City Stkn Lot Size125XX340 PM East Main. Chtt_rch of Christ � I Owner's Name Ken Kinds;, eta! Address same Phone 462-6067 Contractor FlOyd E. Wood I Address 7 N. Adelbert AVE License No. 425276 Phone_ 465-3971 TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ A OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWE INES DISPOSAL FLD, PROP. LINE # FOUNDATION AGRICUL RE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA C S CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di Well Excavation Dia. of Well Casing { I a ❑ Domestic/Private ❑ Gravel Pack C1 Tracy ype o asing Specifications i'1 Public ❑ Other it f Ll Delta Depth of out Seal Type of Grout I I Irrigation __.Approxi Depth I I Eastern Surface Seal stalled by C\ Repair Work Done 17 Type of Pum r V l p P• State Work Done Well Destruction ❑ Well Diameter# Sealing Material (top 501 t Depth Filler Materia! (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION l I DESTRUCTIONAl INo septic system permitted if public sewer is available within 200 feet.! � Installation will serve: Residence—i Commercial t-/ Other Number of living units: Di!k, Number of bedrooms Character of soil to a depth of 3 feet:' I Water table depth ' SEPTIC TANK ❑ Type/MfgCa acit t P Y No. Compartments PKG. TREATMENT PLT. ❑ ! I ; I Method of Disposal Distance to nearest: Well Foundation Property Line i ! - LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well t, Foundation Property Line DISPOSAL PONDS f ❑ 1 , 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 Di%trict. ti_ Home owner or licensed agent's signature certifies the fallowing. "I certify that in the performance of the work for which this permit is issued, 1 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." ; The applicant must call for all required inspections. Complete-drawing'on rammer-se'side. Signed X Title: � � Date: i FOR DEPARTMENT USE ONLY 'I, Application Accepted by n Pit or Grout !Hsps b tion yi'� ~ DateY _ Final'Inspectioby Date t V'. Additional Comment ❑ Stk 466-6781 odi 369-3621 ❑ Manteca 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 j 4I ° FEE AMOUNT DUE AMOUNT REMITTEDWHZ INFO RECEIVED BY DATE PERMIT NO. C J� r.EFF 13-21(REV.1 y 51 �✓ �� Q -7 r / ��/. , EH 14-20 a 4YJ