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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA AUG 11 198 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED £1�lViRIJMEI�TAL HEALTH PERMIT/SERVICES (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 8427 Treasure C4t0ekton Lot Size PM Owner's Name John D. Crawford Address 8427 Treasure, Stockton Phone 931-4136 Contractor PwvienceRr�llerSlDri11is1j�Carp• Address pe 0, Box 649 LiLnder]License No. 377923Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ `DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. P_ROP_..LINE -+ FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casio E g Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I I Irrigation _._Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump SU17 H.P. 11 HP State Work Donere�Tced old t�utnp W Well Destruction ❑ Well Diameter Sealing Material (top 50'1 neW o Depth Filler Material IBelow 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ! I DESTRUCTION l I (No septic system permitted if public sewer is j available within 200 feet.) Installation.will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms rs h 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 171 Distance to nearest: Well Foundation --., � _f Property Line A" SEEPAGE PITS I 1 Depth Size Number SUMPSx._ D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be d_one}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 i 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 plica�mu�' for regwr inspections. Complete drawing on reverse side.- --.- -- �- - - y Signe Title: Corporate Secretary Date: 8/6/87 ' FOR DEPARTMENT USE ONLY Application Accepted by Date " Area ///�r-/ .f Pit or Grout Inspection by '' Data Final Inspection by Date J/2-26-W Additional Comments: C] Stk 466.6781 ❑ Lodi 369-3621:y, ❑ Manteca 623-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + j INFO AMOUNT DUE �• AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. p�1 s r EH13-24 IREV,I/R 5) EH is-2fS �//