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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED R (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 _ Never, P e t ertrburg Job Address .R4 City L iladen Lot Size 1.53 Ae a PM# 2 Ken Forel. a Owner's Name 7460 Orford Rd Address Stockton C8. Phone 6-o Z Contractor's Name _yer Well D_i' _1lI1id3l%e No. 391542 Phone 2 " 11 TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP IfVSTi4CIATlt)N-'❑ 'SYSTEM:REPAIR'0 R; `"''—OTHER–El DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD.�F..100 PROP. LINE 20 . FOUNDATION 60AGRICULTURE WELL OTHER WELD PITS/SUMPS. 15—O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i . f Open Bottom ❑ Manteca Dia. of Well Excavation �� Dia. of Well Casing tt 1 2 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing,.— Specifications 12- Ga ❑ Public ❑ Other ❑ Delta Depth of Giout Seal50 Type of Grout 9 41C 13 '2� Irrigation Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler`Material i8elow,50') TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION ❑ DESTRUCTION El (No_sPptic.system permitted if public sewer is y available within 200-feet.h ; 1 � �� e � "'"F F•a few � ./ Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedroomsr Character of soil to a depth of 3 feet: Water table depth'; SEPTIC TANK "❑ Type/Mfg �Y '� Capacity No. Compartme t !y PKG. TREATMENT PLT. EDMethod of Disposal Distance to nearest. Well .-Foundation Property Line � LEACHING LINE j LJ No.& Length of lines' Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation Property Line ;-Y; SEEPAGE PITS ❑ Depth �� Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line. DISPOSAL PONDS :rED '�t hereby certify that,Phave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and J 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 insuchmanner as to become subject to workman's-compensation laws of-California:"-Contractor's-hiring-or-sijk)�-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 al! for all required ins tions plate drawing on reverse side. Signed Title: Contractor Date:MaY 3p 14$5 1=OR-DEPARTMENT USE ONLY . t (i' Date : ,Area Application Accepted by Pit or Grout Inspection by ate Final Inspection by .,Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . r FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. �'J INFO �' , + EH 3-24 EH 14261AEV.19!831 J-{ y 7