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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 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 Addres§257 East Foppiano Rd CityStkn Lot Size 1 _ 5 acre PM Owner's Name Robert Hammond Address Game Phone 474-84 6 Contractor C1 a rk Wa 77 __ Address 2 fO 2 A_F, hartear License No.�5��_�Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 3Jk SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 n 0 - SEWER LINES DISPOSAL FLD. 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 122 Dia. of Well Casing6 5 2�,n XX Domestic/Private RGravel Pack El Tracy Type of Casing Specifications 9 Sack-#/O/ M Public (7 Other L-1 Delta Depth of Grout Seal 100 _- Type of Groug—aC.k� I I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by ("I-ark _ Repair Work Done ❑ Type of Pump Sib H.P. 3 State Work Done i p 5;J:a I I Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material }Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION i I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Q 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 -Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation J Property Line SEEPAGE PITS I I Depth Size _ _ Number—' SUMPS P Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C '" ; {` 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: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Californ The applicant II f r e red inspections. Complete drawing on reverse side. Signed X Title: NIP r 3 a7 a rk We I I __ Date: 5J6lT p9, FOR DEPARTMENT USE ONLY Application Accepted by Date � ��_Ar_ea T� Pit or Grout Inspection by !f Date ,,(( Final Inspection by q/'' Date V Additional Comments- a 4 t t 19s, � �45f- C/4 1u !7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 racy 83 -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 ♦.EH13-24(REV.r/H51 1,3y.0D tJ� 150— 17 7 EH U-2e "1 L� i