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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDATE 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 9575 E. Victor Dr. Subdivision.Name Owner's Name P. G. & E. Address Victor Ca, 9525f3one Contractor's Name Goehrin -Pump License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT DESTRUC PUMP INSTALLATION SYSTEM REPAIR �. 0TH DISTANCE TO NEAREST: SEPTIC TANK SEWERiLINES ?1 -- _ ,..,. -•4 � DISPOSAL FLD. ,fi PROP. LINE �. �. FOUNDATION- _ .,_ 7AGRICULTURE WELL w !OTHER WELL PITS/SUMPS € INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Indtrial _ omestic/Private usU Open Bottom ❑ Man�eca F... Dia r.of."Well Excavation D U [:] Gravel Pack', .:❑ Tracy Dia, of "Well-Casing, i Public/ ❑ Other Delta Irri at`ion 3 EJ EType of Casing Li 9 1 Approx. astern ggg f-1Cathodic Protection Depth Specifications ❑ Depth of Grout Seal Geophysi'cal a ri Other �,• Type of Grout � , . Surface Seal Installed by Repair.-Work"Done-E] Type of Pump fl.P. State Work Done ,t " Well Destruction U Well Diameter 6 Sealing Material (top 50') 5--Sack Concrete Depth 157 ft. Filler Material (Below 50') Sanitary Gravel F I J i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer lis' "` w available .within 200 feet.) E Installation will serve: Residence _ Commercial _ Other ter, Number of.living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK . L Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal rr SEWAGE SYSTEM �1 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No., & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line - SEEPAGE PITS•-- Depth._ -.Si?e. .� - _ Number I SUMPS UDistance to nearest: ,Well Foundation Property Line -� DISPOSAL,PONDS ❑ e t. r .11 I I I YIYi� i•I ningilp�i.n. m i I hereby certify that I have prepared this application and-that the -work will be done in accordance with San Joaquin county 0 ordinances, state laws, and rules and r�egulationsiof.the San Joaquin.Local Health District, Home owner or licensed agent's signature certifies t6 following: "I certify that in the performance of the work for which this l permit is issued, I all not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hi r sub-contracting"signature certifies the following: "I certify that in the performance of the work for which this permit i d, shall employ persons subject to workman's compensation laws of California." - ..:'�;< The applica c 1 far all required inspections. Complete drawing on reverse side. Signed X ._ T;itle: Bkpr. Date 12/19[$6 T NLY �y, Application Accepted /.- Area C �d G�cT6 - ❑ Stk ;:466-6781 Additional Comments: V Lodi ;: 369-3621 F- Pit or Grout Inspection by Date ��' � a MantecaR8�3-7104 Final Inspection by lt��'„ Date ❑ Tracy'«05-6385,-- Applicant 5-6385 Applicant - Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box;$0D9; 5tk.,�CA 952 OK' FEE .._BASE— —AMOUNT,..DUE._,,,,. -.—AMOUN,T-,•REMIT.TED_-._..-•..,,,,,.RECEIVED BY -.r.. _DATE PbiWT INFO . ... _ t 4 EH 13-24 REV. 10/82 10/82 500 14-26