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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,.STOCKTON, CA 'Telephone (209) 466-6781 kF_ _ 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. i Job Address 5011 E DANA city STOCKTON Lot Size-_ " PM Owner's Name Address 5011 ,E•.- DANA Phone 466-7657 Contractor iTFTTFR PT.RG. COAddress 1035 S AURORA ST. License No. 202228 Phone 463-1706 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ,OTHER'WELL PS INTENDED USE TYPE OF WELL PROOL ONSTRUCTION ATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca D' vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications f ❑ Public -T❑ OtherDelta Depth of Grout Seal y r ❑ Irrigation x. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P. State Work Done Well Destructi ❑ Well Diameter r Sealing'Mat605I'(top i Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑1 REPAIR/ADDITION El ..DESTRUCTION INo septic system permitted if public sewer is Ja t. . 1 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: - 1- •- w- --- Water table depth SEPTIC TANK ❑ Type/Mfg t.- ` Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Mefhod of Disposal Distance to nearest: Well 'AMS Foundation' Property Line I � f LEACHING LINE ❑ No: & Length'of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS ❑' Depth Size Number 1 SUMPS ❑ .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 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 r 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." Theapplicant m t call for all re uir pections. Complete drawing on reverse side. Signed x Title: PRESIDENT Date: 4/15/87 r FOR DEPARTMENT USE ONLY Application Accepted by Date Area 03 '11f Pit or Grout Inspection by Date Final inspection by + Date Additional Comments: 5 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Me teca 823-7104 ❑ Tracy 8355-6385 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 OK RECEIVED BY DATE PERMIT'NO. INFO + Eli13-24{REV.+i A 57S EH 14-26