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{! APPLICATION FOR/PERMIT SAN JOAQUIN LOCAL WEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYM�� Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED RECEIVgo (Complete in Triplicate} MAR f s. Ism , SAN Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ( made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and t ��rcation is Local Health District. �' S' � 6nquiin Job Address 222 North El Dorado S City Stocktori Lot Size 16Tg9osq f pM Owner's NameAmericaii Savings Rank Address 400 E, Main St,z Stockttln Phone 1209). I Contractor AddressStor-k-ton License No.C-57_#5122�stphone TYPE OF WELL/PUMP_ NEW WELL IR WELL REPLACEMENT ❑ DESTRUCTION-C] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL moaitorineITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS EI Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation 8 inches Dia. of Well Casing 4 inches 91 Domestic/Private Rl Gravel Pack ❑ Tracy Type of Casing PVC Specifications F] Public ❑ Other lA Delta Depth of Grout Seal A2prox 30 ft Type of Grout neat cement i I Irrigation 50FApprox. Depth I i Eastern Surface Seal Installed by Spectrum Exploration Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Fl REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is ,}�9 w Installation will serve: Residence— Commercial— Other available within 200 feet► Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth i ❑ Type/Mfg Ga acit p Y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ElProperty Line 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 Dt%trict. Home owner or licensed agent's signature certifies the followin em to an g: "'I certify that in the performance of the work for which this permit is issued, I shall not ploy y 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 em to tion laws of California." p y persons subject to workman's compensa- 1 The applican m st c for all eq ired inspections. Complete drawing on reverse side. Signed X ' Title: Supervisor of Geology Date: February 21, 1991 v FOR DEPARTMENT USE ONLY 9 Application Accepted by Date / Area Pit or Grout Inspection by Data Z— Final Inspection by Date - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 Applicant - Return all copies 1.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk„ CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY OATS EPM(TNO.XZ EH 13-24(REV.1/H 51 EH 14-29 `r � �6Q/