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APPLICATIONFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT rAYMtL�. 1 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUL V, 1990 j (Complete in Triplicate) ENVIRONMENTAL HEALT ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hater),„ f(+�t®d�1ThA'application is. with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations o thhe San Joaquin in compliance q made P Local Health District, Job Address 2651 S. Airport Way City Stockton Lot Size PM — B Rainbo akin Co Address 'DAF+ Mnnt Itm r r SactOrCA Phone 6 /4563863 Owner's Name Addg y qSG-3 Anderson Geo. 631 Commerce Dr RCAevilie Contractor Address License No. 5(1RdQ5 Phon,916 786—Ei8 3 TYPE OF WELLIpUMP: NEW WELL El WELL REPLACEMENT LJDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERXX MOni�orii DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ± 100' DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL Q0 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n ❑ Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ; ❑ Domestic/Private (XGravel Pack ❑ Tracy Type of Casing PVC Sch 40 Specifications I"1 Public ❑ Other ❑ Delta Depth of Grout Seal 25 ' Type of Grout_Cement I I Irrigation 55_Approx. Depth I Eastern Surface Seal Installed by Tremle _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 X Monitoring Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I JNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table e SEPTIC TANK ❑ Type/Mfg Capacity-- No. Comp PKG. TREATMENT PLT. ❑ _ Method of i Distance to nearest: Well Foundation Property Line _Rk10 14 1990 LEACHING LINE ❑ No. & Length of lines Total length/size FNVIRONMEN -FILTER BED ❑ Distance to nearest: - Well Foundation Property Line ''PERMIT/SERVIC ES 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 call for 11 required d�'pspections. Complete drawing on reverse side. . Signed X �� Title: lv BD to;l5T Date: 0 FOR DEPARTMENT USE ONLY q �j Application Accepted by / r t ` Date 8 p r- Area q,30 Pit or Grout Inspectidn'"6y Date -0Final Final Inspection by -- Oate� 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 DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO (_�1 �X]/I! `y' G S EH 13-24 UIEV.Iias� 1—' U { O �S� tel.� EH AF a