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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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 compli roto 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 Dratrict. Job Address 7644 Ashley Road_ city Stockton Lot Size 1 Acre PM Pacific Bell Owner's Name Management & Cons tructiOrAddress __P-0- BOX 15038, Sacramento Phone _L9_1 6 374-2417 -- - — — CA, 95851 Contractor Woodward Dr 11 i ng Address Box 336 Ri o Vi std CA9457Llicense No�57581639 Phone_(707)374-43 0 ' TYPE OF WELL/PUMP: NEW WELL [.I WELL REPLACEMENT 1l DESTRUCTION LI PUMP INSTALLATION 11 SYSTEM REPAIR [l OTHER 0i Vapor Extraction DISTANCE TO NEAREST: SEPTIC TANK .30 fee_ SEWER LINES ____ DISPOSAL FLD. PROP. LINE FOUNDATIONI.O feet_ AGRICULTURE WELL _ OTHER WELL5-0feet PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial V Open Bottom 1.1 Manteca Dia, of Welt Excavation_�Z�`�— Dia. of Well Casing 411 1,1 DUmesllc/Pnvale 1.4 Gravel Pack Ll Tracy Type of Casing PVC Specifications ' I'I Public IA Other Il Delta Depth of Grout Seal _Ml n 5' Type of GroutCemenl_wi t_h 1 I Irrigation __— Approx. Depth l I Eastern Surface Seal Instdlfed by Dri 11 e `Bentoni tl� _ Repair Work Done [_7 Type of Pump H.P. State Work Done _ ' Well Destruction f i Well Diameter Sealing Material (top 501 _TO-.BeDetermined —_ Vapor EXtractiol'bepth Filler Material (Below 50') NIA TYI1C OF SEPTIC WORK: NEW INSTALLATION I t REPAIR/ADDITION t I DESTAucTION I I (No septic system permitted if public sewer Is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of hVIFIg units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK I I Type/Mfg Capacity-__ No. Compartments PKG. TREATMENT PLT. n Method of Disposal Distance to nearest: Well _ Foundation Property Line ' LEACHING LINE t.! No. & Length of lines Total length/size FILTER BED [_I Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation __ Property Line DISPOSAL PONOS f 1 I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and ragulalions of the San Joaquin Local Health Di1trict. 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 porson in such mannor as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follo ing: "I certify that in the rfontlanea of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C- i rnia." The applican i us - r all req ii pe tions. Complete drawingo reverse side. SEE FIGURES ATTACHED Signed X_ _ — Title: _�J'� � � S if Date _ ' FOR DEPARTMENT USE ONLY Application Accepted by _11yC 'a-,l Date �.1 Area Pit or Grout Inspection by ' 1 Date Final Inspection by Date Additional Comments: a 0 Sik 466-6781 0 Lodi 3693621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Heelth Permit/Services 1601 E. Hazolton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT 1 AMOUNT REMITTED CASIt RECEIVED DATE �y PERMl7'Nq, ' CH 1]-24114EV.1/1151 4i� a t~ �-_ J 1i I EH 14 26