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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (205) 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. r Job Address 2.5'902,N. Pearl City Gal-t tot Size 5 Ares PM 6 Owner's Name Ed Hansen Address 24700 Suttonfield Acam o Phone36 — Contractor Jerry Jay &• AssoC-Address 1000 N. Union St. License No. 394241 Phonel1152-1481 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Pubfic f O Other ❑ Delta Depth of Grout Seal Type of Grout F1 Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑: Well Diameter ' Sealing Material stop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC.WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is , r available within 200 feet.) �✓ Installation will serve: Residence R Commercial— Other Number of living units: 1 Number of bedrooms 3 S Character of soil to a depth of 3 feet: Sandy -Clay Sandy—ClayWater table depth SEPTIC TAI4K L:� Type/Mfg Concrete Capacity 1200._ No. Compartments PKG. TREATMENT PLT. ❑ .. Method of Disposal r w 4�Z Distance to nearest: Well 100+ Foundation 25Property Line- 125+ S- LEACHING LINE 9 No: &Length of lines Three 3 x a�1 ,Notal length/size .2 6 �. a FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS epth Size INun)ber_13 ____�_ SUMPS ❑ Distance to nearest: Well �Found�atfiion / Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that fie 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, I shall employ persons subject to workman's compensa- tion laws of California." ,The applicant must I for all require nspections. Complete drawing on reverse side. j igned Title: Prsident Data: 4-9-86 I FOR DEPARTMENT USE ONLY Application Accepted by t— Date Area r Pit ' r Grout Inspection by � 7 -' Final Inspection byj " "I1 i c Date, zY�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6305 'F Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED By DATE PERMIT NO. + EH 1 3-241REV.1/85) EH 4.2e