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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (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. C Job Address 6215 Roberta Place City Stockton Lot Size PM Owner's Name Don Collier Address 621.5 Roberta Place Phone 931--2120 Contractor ;Clark Well Address 2024 R Charter Wa License No. 317560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i"i Public t F= Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ' Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done N Type of Pump S u h H.P.__2 State Work Done Tn s t a l e d Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installationwill 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 SEEPAGE PITS i I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ r � I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county or�inaoWs, state laws, and rules and r lations of the San Joaquin Local Health District. Home owghfp r license ent's signature certifies the following: "I certify that in the performance of the work for which this pArmit is issued, I shall not employ arson in ch anner as to ome sub t to workman's compensation laws of California."Contractor's hiring or sub=contracting signature certifies tlowing: 'I ce fy at in rforma of the work for which this petmit is issued, I shall employ persons subject to workman's compensa- tion lawsalifofnia. The applit Icall r al uir i ons. mplete dr wing on reverse side. Signed X Title: Sec—Tres Date: April 7, 1.989 O MENT USE ONLY Application Accepted by f pate Area 103 Pit or Grout Inspection by Date Final Inspection In �f.tnn _ Date Additional Comments: _ ❑ Stk 466,6781 ❑ Lodi 369-3621 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. CH 13-24 fi • EH t4-2a(REV,t/>+51 l r)— II !Fg--I I