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APPLICATION FOR PERMIT ..', SAN JOAQUIN LOCAL HEALTH DISTRICT C, 1601 E. HAZELTON AVE., STOCKTON, CA r-.-r o ®U I U Telephone (209) 466-6781 I-PERMIT EXPIRES VYEAR FROM DATE ISSUED (Complete in Triplicate) pEr1 4;,SEItVI�I S 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. 1662 for weNl pump and the Rules and Regulations of the San Joaquin Local Health District, 51.21 East Mariposa Road City Stockton Lot Size PM Job Address ill Mrs GUS Kerkanes 51.21 E Mariposa Rd Phone 46t46 944 Owner's ppName JJ Address I Clark We'll l Address 2424 E Charter Way License No. 371560 Phone -7676 Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF:WELL/PUMP: `�NEW WELL ❑ OTHER ❑ qh PUMP INSTALLATION I$ SYSTEM REPAIR ❑ !I pESPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK_`* SEWER LINES FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUGTION SPECIFICATIONS pia. of Well Casing ❑ Industrial D Open Bottom ❑ Manteca• ` Dia. of Well Excavation Specifications -A ❑ Dome 'stic/Private ❑ Gravel Pack ❑ Tracy I ` = Type of Casing Typo of Grout Cl Other F1 Delta Depth of Grout Seal _ — ❑ Public �`'��,.. �l A rox. Depth I I Eastern ace Seal Installed by I I Irrigation --- PP Installe d Repair Work Done ❑ Type of Pump Sub H.P. State Wark Pone Well Destruction ❑ Well Diameter Sealing Material Stop 501%, d t t Depth Filler Material (Below 501 N TYPE70'F SEPTIC WORK: . NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION l I+(No septic system m Pal feet.) if publiJ�s dlih Other Installation'will serve: Residence� Commercial,— �"r� Number of living-units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth ` No. Compartments SEPT14TANK 3 ❑ Type/Mfg Capacity i Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: " Well "' °""'"'""Founda`tib i' "Property Line!^^ i 1 y LEACHING LINE ❑ No. & Length of lines Total length/size FILTE41IBED ❑ Distance�to nearest: Well Foundation Property Line SEEPAL E PITS 1 1 Depth I Size Number { SUMPS L-1Distanceto nearest: Well Foundation Property Line DISPd'AL 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 DtItfict. Home"owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall,not employ any son in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i certifies the fol wing: „ rtify that in the rforman of the work for which this permit i5 issued,I shall employ persons subject to workman's compensa- tion laws o C ifornia. k The applican ust caH uir d n ctions. 1mplete drawing on reverse side. 1 x/26/88 f } Title: Sec-Tres Date: Signed X " - FOR DEPARTMENT USE ONLY r Date ( Area Application Accepted by I I f(�/i r Date Pit or'I -1 Inspection by Date Final Inspection by Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CJ Tracy 835 6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT NO. CASH INFO / +.EH 13-24 IR�EV.i/n 51 I ! 1/'I EH 14-28 I� L _