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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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. }' tockton Lot SIZe880 Acres PM .lob Address 9099 N. Mariners Dr.. GityS Owner's Name John C. Kelley Jr. Address 8099 N. Mariners Dr. Phone 477-1207 G} ' Contractor's Nam,Jerry Joy Assoc. License No. A 394241 Phone 462-1481 TYPE OF WELL/*UMP: NEW WELL ❑ WELL REPLACEMENT ❑ 51STRUCTION C] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I, E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINfS DISPOSAL-FLbL:: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing * Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typle of Casing 11 Public *❑ Other ❑ Delta Depth of Grout Seal * Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surfage Seal Installed by ` Repair Work Done ❑ Type of Pump H. P. State Work Done* �l j Well Destruction ❑ Weil Diameter Sealing Material (top 50'1 Detith }I Filler Material (Belot 501 TYPE OF SEPTIC WORK: NEW INSTALLATION JI REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence yCommercial_^ Other Number of living units: 1 _ Nulrnber of bedrooms 2 ` Character of soil to a depth of 3 feet: Adobe Clay Water table depth ' SEPTIC TANK EX Type/Mfg Capacity. 12 0 0 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑{ No. & Length of lines 9 ' Total length/size_1A0 4.1' — i FILTER BED CIDistance to nearest: Well 0 Foundation 45 Property Lira /A �\ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearestk Well Foundatioft Property Line* DISPOSAL PONDS * ❑ 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. 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:11 certify that'in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compense- tion laws of California." ' The applicant must I for all r `uired in pections. Complete drawing on reverse side. d �,..�.« - Title: Date: A11C311 t 1 2, 1 9 8 6 fine i FOR DEPARTMENT USE ONLY L Date Application Accepted by Pit or Grout Inspection by Date final Inspection by Date -A4d�itional Comments: �Stk 466-67131 ❑ Lodi 369 36'21 ❑ Manteca 823-7104 ❑ Tracy 835-M fApp__iicant - Return all copies to: EnvIi nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED % CK RECEIVED BY DATE PERMITNO. f INFO ou + EH 1324(REV.101331 —7 • a 7�, �� EH 14-25