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APPLICATION FOq• PERMIT SAN JOAQUIN LOCAL Ht ALTH DISTRIf 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVEo PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) MAR 13 1991 SAhN AU IApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the �L I ��'cattii�on is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and ti �� l� l �JlfllVaquin Local Health District. Job Address 222 North El Dorado Street City Stockton Lot Size 1F,Tpgggt PM Owner's Name Amer;ran Savings Bank Address 400 E. Main St., Stockton Phone1;4(;-)414 Contractor Rpt-ntn,m F.x= nratJon Address 2825 E_ Myrt1P St_,, stnrktnn License No.0-57, #512268Phone - TYPE OF WELL/PUMP: NEW WELL l WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL monitorin?ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 inches Dia. of Well Casing 4 inches ® Domestic/Private KI Gravel Pack ❑ Tracy Type of Casing PVC Specifications M Public M Other IN Delta Depth of Grout Seal Approx 30 ft Type of Grout neat cement _ I I Irrigation SOrApprox. Depth I I Eastern Surface Seal Installed by Spectrum Exploration _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ (� TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I (No 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 depth SEPTIC TANK O 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 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 applicanlqt c for all eq imd inspections. Complete drawing on reverse side. Signed X "Y Title: Supervisor of Geology Date: February 21, 1991 FOR DEPARTMENT USE ONLY Application Accepted by Date �•/ Area Pit or Grout Inspection by r Date Z Final Inspection by,A6 Date� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 O Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED BY DATE P IT'N a EH13-241REV.r/n51 00 EH 74-28 (� 7