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APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 SANJOA�QU{/�INCOUNTY-rt lf[?i�A>�i MAR FROM DATE IS Application is hei�"-'•ONMENTAL HEALTH DIVIS) mplete In SUED made in compliancey made to th S n a Triplicate) f"FER 0 t b- 31 710 nQ�y7EP�y& }gtrict for 1 199 Local Health Districts. u��y (�i�h�r�b74'9 Permit to construct and/ install the wotknl„e. •7 for sewage or No. 1862 for well/pomp and the Rules a t�a�•bHe_d. This application is Job Address 440 West Charter WayWR %f%f"a"'Joaquin Texaco Reng and City Stockton Owner's Name Markpl_i nn 10 U111versal Cl—_'t� Lot Size 2001-150,_.___ PM GrOundwa� . Address Universal Cit y Plaza Contractor Technolo 1ncSi 'r 1401 Halyard Dr. , Suite phone (8tg) address West Sacramento 140 5 ?47 TYPE OF�UMP, Ca. NEW WELL in License No. 4343_Phone 91 PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ 372— 7 DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ DESTRUCTION ❑ —_ FOUNDATION SEWER LINES OTHER B--AY?yam, i�l �l 7 DISPOSAL FLD, pgpp LINE _ AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA OTHER WELL PITS/SUMPS _ 17 Industrial ❑ Open Bo omN --- CONSTRUCTION SPECIFICATIONS Ll Domestic/Private ❑ Manteca Dia. of Well Excavation 10.5" LI pack ❑ Tracy �— Dia. of Well Casing Orr r'I Public fl Other Type of Casing PVC Ll Delta Depth of Grout Seal 2S' Specifications I I frrrgation _—Approx. Depth I I Eastern �t— Type of Grout Surface Seal Installed by Contractor 'mat t pmpnt. Repair Work Done ❑ Type of Pune H.P. Well Destruction ❑ Well Diameter " State Work Done_ Sealing Material (top 50') _$entpnl tp and Nr t n x-Monitoring Well Depth 4$-- Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet..........l Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. L_7 Capacity No. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.3 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L1 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 D13trict. Home owner or licensed agent's signature rxrtifies the following: '9 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 became 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 applicantX11 for all` uon Complete drawing on reverse side. Signed x- � wr' 0, GY Title: e01 ist7Slte suWrvisor Date: hb �� f6ijAEPA NT USE ONLY n /) Application Accepted by fid{/ Dates'` Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ Manteca 823-7104 ❑Ttacy 83S-6385 P[Ip1ic1IR1-R6lOt0 all COP19a to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f I' cK RECENED aY DATE ASH PERMIT NO-56. l AMOUNT REMITTED yo AMOUNT DUE Z—j INFO