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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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 Address 15988 E• Eight Mile Rd. , St09k.t0n,C4,a Lot Size PM owner's Name George�L Pierre Address 5760 Bell Rd. AUb3Anax _Ca Phone 3554 Contraca D ill Adm P-0-130m' 64.\U + -icense.No. 377923 _Phone 887= TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 19 SYSTEM REPAIR ❑ OTHER ❑ -r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial (k Open Bottom 1711 Manteca Dia. of Well Excavation_ 10 Dia. of Well Casing i \ I JE Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .4-I-PPI Specifications 3/16 M Public ❑ Other Ll Delta Depth of Grout Seal -50 ' 15")-- Type of Grout cenent I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done LI Type of Pump ub H.P. 11 State Work Done new well new p �; Ump DO Well Destruction O Well Diameter, y Sealing Material atop 50') 'Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I .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: ❑ Method of Disposal 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 t , SEEPAGE PITS I I Depth Size Number f SUMPS L� 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 i rules and regulations of the San Joaquin Local Health DF%trict. 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 —..e mploy anyapersoon in such.manner as-to-become subject tto-workman's-compensatiomlaws-of-California.";,Contractor's hiring orsub 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- i , tion laws of California." r t The appli t must fall r squired inspections. Complete drawing on reverse side. ` Signed 'X Tale: President Date: 6/2/89 i - - ` FOR DEP RTMENT USE ONLY g / l �/ �T Application Accepted by Date Area ISL Date_C Pit or Grout inspection by Date��Final Inspection by' , Additional Comments: / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 c. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 >�r y FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED By DATE PERMIT'NO. r INFO CASH +.EH73-24(REV.i/H 5) EH 14-29 -