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r 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 t x: (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 W/S Castle Rd. 4/10 mi N/0 Northland R Stockton itY Lot Size PM Owner's Name pacific Gas & Electric Address P.O. Box 930 Stockton 95201 942-1539 Phone Contractor General ConstructiOrAddress 4055 E. Hwy, 120 License No. 823-0081 Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE AL FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! Open Bottom Q Manteca —Dia ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public K Other CA74"1`0 Delta Depth of Grout Seal r Type of Grout ""naz1Q4VIT '119 -- "12 pprox. Depth IJ Eastern Surface Seal Installed by Pacific Gas & electric CO. , RepairWork Done ❑ Type of Pump N/A H.P. N A State Work Done_ Well Destruction ❑ Well Diameter Try— Sealing Material (top 50') Concrete r p Depth Filler Material {Below 50'} COke breeze TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 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. © N/A Method of Dis osal . p ; Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size1 Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ H I 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 f 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 call for all required inspections. Com late drawing on reverse side. Signed X John Hoube.in Title:. En ineer-Estimator Date: 1-17-86 , FOR DEPAR ENT USE ONLY f' Application Accepted by Date "' P.00Area ©4p 1 Pit or Grout Inspection ate _ Final Inspection by Date s A ' Additional Comments: V d LAJ a C Q d ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO DATE PERMIT'NO, d ' + E" 3 24(REV.1/8 5) Gv � EH 14-18 70 / � � Qct CA—