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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA —1 - 3 3 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 2155 S. B Street City Stockton Lot Size 15.3 Acre PM Owner's Name Larry Dorn Assoc, Inc. Address5550 'lshire Blvd Los Angeles Phone213 935 6266 Ctractor` Address 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL R EPLACEMEN DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM RE IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULT E W OTHER WELL PITS/SUMPS Q, INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTION SPECIFICATIONS v El Industrial El Open Bottom ❑ Manteca ra. f Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Casing Specifications 1n1 F'1 Public ❑ Other ❑ Delta Depth o Grout Seal Type of Grout _ 1A 1 1 Irrigation --Approx. Depth I I Eastern Surface Se Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I i F15-1AIR/ADDITION I I DESTRUCTION V(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commerciai-._— 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 SEEPAGE PITS I I Depth Size _ Number 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 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 c require ms ctions. Complete drawing on reverse side. Sign} d X _ Title: Pp¢i dent Date: 3 91/RR FOR DEPARTMENT USE ONLY App nation Accepted by _._ Dated Area Pit or Grout Inspection by DZ < Final Inspection by Lam' t Date Additional Comments:: W ov - h or) 1 "-e U -e 6, -e 0 L_,,kPV ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 0 f Pr i r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ) �UTll �U �{ SV �(�n �y[cCT,od (.. v v�ti►� (-c- fl-UV-A/ o, LUt, � ��r"`�ILFEE �v INFO �--MOUNT DUE AMOUNT REMITTED ASHRECEIVED BY DATE PERMIT•N"O. 12I ) +,EH 13-24(REV.1/85) r- . Vt JJ:7;, q r EH 14-26 3 CJrf ?