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' APPLICATION FOR PERMIT N.0 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 2400 Airport Way, city Stockton Lot Sire 140 x 170 pm 169-100-29 Owner's Name Mr. Ulycess Williams Address334 Olympic Circle, Stockton Phone 948- 8267 Contractor Spectrum _Exploration Address 2826 E. Myrtle ki0 lSe No. (C-57)(C-57) Phone -19712_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E DESTRUCTION ❑ PUMP INSTALLATION L] SYSTEM REPAIR Cl ERX�X Solt Borings (3) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. OP. LINE �n r FOUNDATION —51 AGRICULTURE WELL OTHER WELL PI /SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION PECIFICATIONS U Industrial U Open Bottom ❑ Manteca Dia. of Well ExXS3,eal Ori ngS pia. f Well Casing P Domestic/Private LJ Gravel Pack C7 Tracy Type of CasingSp ifications F1 Public n Other 1� Delta Depth of Grout T e of Grout---- 1 rout __ — .- i I 1 Irrigation 25 Approx. Depth I I Eastern Surface Seal InRepair Work Done ❑ Type of Pump H.P. rk Done Wen Destruction ❑ Well Diameter Sealing Material (top ) be l l ed with neat cement Depth Filler Material {Below } TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DERUCTION I I I septic system permitte "t-iNj sewer is vailable within 200 fee Installation will serve: Residence_____ Commercial Other Number of living units: Number of bedrooms+—L Character of soil to a depth of 3 feet: Wa r SEPTIC TANK ❑ Type/Mfg Gapacity o. C rtments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Fo ndation roperty Line—MAS-,4 1985 LEACHING LINE Cl No. & Length of tines otal length/size ;;rx VII"NAAtN IAL HEALTH FILTER BED 1-1 Distant to nearest: Well Foundation Property Line FERWI VICES SEEPAGE PITS 11 Depth ize Number SUMPS LI Distance to neo t: ell Foun tion Property Line DISPOSAL PONDS L7 I hereby certify that I have prepared this application d t t the work will a done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health 3t 'ct. Home owner or licensed agent's signature certifies the fol ing: "I ce 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 workr � 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." LL// The applicant must call for all uir inspections. Complete drawing on reverse side. Signed X Title: � lZf/ i- YDate: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: IJ 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, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24 IREV. n5) EH 1128