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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (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 AddrJ257 East FO fano Rd CityStkn Lot Size 1 _ S acre PM s Owner's Name Robert Hammond- Address SaTTIP Phone 474— Contractor --Address License No.__3_7_175,&4D__Phone 4 62 767 6 TYPE OF WELL/PUMP: NEW WELL J(j�C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 2k SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100_' SEWER LINES DISPOSAL FLD. PROP. LINE r j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of Well Casins6 5. 811 XX Domestic/Private 9 Gravel Pack ❑ Tracy Type of Casing Specifications 9 sack/ [� -,Ade r ❑ Public Cl Other C1 Delta Depth of Grout Seal Type of GrOt1prk�____-. I I Irrigation —_Approx. Depth i I Eastern Surface Seal installed by Clark _ Repair Work Done ❑ Type of Pump Silh H.P. 3 State Work Done J_n-- tII Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence— Commercial_ Other d Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity � No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines " Notal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ` I hereby certify that I have prepared this application and that the work will be done in accordance withYSan 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 Cal ifornia„•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 Califom' The applicant II f r eq red inspections. Complete drawing on reverse side. Signed X Title: N7P Clark Well Date: 5 jUly °() FOR DEPARTMENT USE ONLY Application Accepted by Date L Area Pit or Grout Inspection by ff Date Final Inspection by "� Date Additional Comments: 4 4 t ! fJ -� c.5 1 k 4 ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 racy 834-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ` +.EH 13-24 IREV.I/H 51 1_3Y.o u _ � qt)-- 1 �p qo EH 1426 S2 i