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` a APPLICATION FOR PERMIT ag 9: � s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) ti 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 f ules and Regulations of the San Joaquin Local Health District. P Job Address 2402 North Pacific Avenue City Lot Size 50X100 ocPM' Stockton ' California Fuels Owner's Name Address P.O.P0Box 1207 95201 {209) �l`6b--5g21 Phone Consults t Lam"- taal,Gardner&D1mne Address 121 No. Fir St. , Suite , , _ (805}653-555 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElpESTRUCTfON ❑ I PUMP INSTALLATION [71�.;. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SYSTEM REPAIR ❑ OTHER & SOil Vapor Survey DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS, , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation IX Domestic/Private ElGravel Pack C1 Tracy T Dia, of Well Casing Type of Casing — Specifications M Public XI Other ❑ Delta Depth of Grout Seal 12-0 f I Irrigation Type of Grout yOlCI_ay D 4 �J J �..Approx Depth iX Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - State Work Done G Well Destruction ❑ Wel! Diameter 8—inch Sealing Material (top 501 Depth 121 feet Filler Material (Below 50') volclay bentonite (� TYPE OF SEPTIC WORK: NEW INSTALLATION 7 REPAIRIADDITION I I DESTRUCTION E I (No septic system permitted if public sewer is k Install a series of temporary Soil Vapor prones Installation will serve: Residence available within 200 feet.) i Commercial_ Other Number of living units: Num4er of bedrooms Character of soil to a depth of 3 feet:I SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity �No. Compartments 'IMethod of Disposal Distance to nearest: Well Foundation t Property Line i LEACHING LINE ❑ No. & Length of lines ) FILTER BEDTotal length/size ❑ Di } stance to_nearest: Well Foundation ( Property Line SEEPAGE PITS 1.1 Depth Size a — Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS Cl Property 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 DoItfict, Home owner or licensed agent's signature certifies the following: "I certify that in the' rformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to wdrkman'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,1 shall employ l tion laws of California." ' p y persons subject to workman's compensa- tion applicant must call for all required inspections. Complete drawing on reverse side. k Signed X Staal Gardner Dunne, Inc. t Title: �jl aJ 'S ,2 Date: FO D AR USE ONLY Application Accepted by r 133 Pit Date r 1 Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED K INFO H RECEIVED BY DATE PERMWNO. M .."""EH1241RpV.Iin51 'H T4-4-2a