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Y � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 1-024 F, Alpine Ave. �;tyStockton Lot Size PM Owner's Name Kearney - OF Address Same Phone ContractorAl l Terrain Drill i ng Address 2789 Liberty Lane License No. Phone_ TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 11p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [XI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private EX Gravel Pack ❑ Tracy Type of Casing 2 i nr–h PVC Specifications _ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 5 ft. Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.NJA State Work Done_ Well Destruction ❑ Well Diameter 2 i nCh Sealing Material (top 501 Depth 40 ft. Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IX REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other X Number of living units: Number of bedrooms N/A Character of soil to a depth of 3 feet: Water table depth J� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE�' El No. & Length of lines NJA Total length/size FILTER BED N/A ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPSN/A ❑ 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 Q 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 o ifornia." The app scan ustNcall for I requi d i ctions. Complete drawing on reverse si Signed ,r Title: �1^ k—A Date: ` - ✓r Uy _ FO EAZRT USE ONLY Application Accepted by Date ea Pit or Grout Inspecti y Final Inspection DateAf Additional Comment Stk 466-6781 ❑ Lodi 3621 Manteca 823-7104 ❑ Tracy 835 Applicant- Return all copes to: Environmental Health Per it/Services 1601 E. H zel on Ave., P.O.`Box 2009, Stk., CA 95201 aZ,a�� ff INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. + EH 13-24(REV.1/85) O.3S, 1 EH 14-28 S C J Si 8 b 3 i