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APPLICATION FOR PERMI% 6 ee SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA a ffQch e- Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEQoN JOAQUIN LOCAL HEALTH DISTR (Complete in Triplicate) ENVIRONMENTAL HEALTH DIIVISIO Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he5fl e�s`df %e Lr s'S ica i n 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 440 W Maxtor Way City StCCIStM Lot Size PM Texaco Ref inincr ddress 10 TTn; prQial r't plaza Phone Owner's Na z f;G r-av��n[cTcar I1, Contractor Sierra PaCifiC EXDl- Address License No. Phone 41 5-AAr.925 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ SOIL <LIS r17uD PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER -A �L H ' k-I[rkYa.c5_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J5'35 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation8:25 rr _ Dia. of Well Casing " ❑ Domestic/Private E:kGravel Pack ❑ Tracy Type of CasingCh,-40--pV4- Specifications 1-1 Public ❑ Other a Delta Depth of Grout Seal * 39' . Type of Grout_E3ort —. I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Cont Ctor_ - Repair Work Done ❑ Type of Pump H.P. State Work Done . Well Destruction ❑ Well Diameter 8 25^ Sealing Material (top 501 X Mnnitnr'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is •1 available within 200 feet.) G Installation will 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 j^ Distance to nearest: Well Foundation Property Line I/ 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 ❑ 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 D3trict. Home owner or licensed agent's signature certifies the following: "I cenify 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."Contractoes 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." SAN JOAQUIN LOCAL HEALTH DISTRICT The applicants must�cJll,for aalllrequired inspections. omplete drawing on reverse side. , EI II�I,VIRONMENTAL HEW Signed X /' �'^'K 1� ��=� Title: �O '$ 11/✓1r• SPECLU PLS 1 FOR DEPARTMENT USE Application Accepted by Date Ar a �� ''��-, sa3 Pit or Grout Inspection by Date Finer Inspection b Date �- Additional Comments: ❑ Stk 485-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEO E AMOUNT DUE AMOUNT REMITTED 5H RECEIVED BY DATE PERMI7'NO, ♦.EH 11INF2/IREV.r/x61 •Q` '7�^ 5 �q -1✓�.( � EM 1426