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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 compliance with San Joaquin County Ordinance No.649 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jos Address 2251 Hot 1 enbeck Road ' - city Stockton_ Lot size 3 acres_ pM_ owners Name Union Safe Deposit Bank Address 327 Fac Main Phone 946-5178 contractor's Name Jerry Joy & ASSOCiate&ense No. 39424 _ __ Phone 4621481 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN'--S DISPOSAL FLD.__ PROP. LINE _ FOUNDATION AGRICULTURE WELL 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 Casing-__ _ Specifications ❑ Public O Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. _ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 509 Depth Filler Material (Below 501 _ — ... TYPE OF SEPTIC WORK: NEW INSTALLATIONO REPAIR/ADDITION I] DESTRUCTION El (No septic system paimitted if public sewer is available within 200 feet.) Installation will serve: Residence xx Commercial_ Other Number of living units: 1 Number of bedroom 3 Character of soil to a depth of 3 lest: Adobe -_ __Water table depth__SO t SEPTIC TANK AX Type/Mfg Concrete capacity 1200 _ No. Compartments TWO _- C PKG. TREATMENT PLT.❑ Method of Disposal _ (� Distance to nearest: Well Foundation Property Line (� LEACHING LINE 6dc No. & Length of lines Two (2) --- Total length/sIz. R."enty—fivr (751) FILTER BED ❑ Distance to near"t: Wen 200 Foundation 16 Property Line SEEPAGE PITS Xx Depth 251 size 331 Number. Tran (9) SUMPS ❑ Distance to nearest: Well 200 . Foundation_9n __ Property Line 30 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." 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." The applicant must call for all required in ctions. Complete drawing on r r side. r_ Signed 1-- Title: Date: l� FOR DEPARTMENT USE ONLY Application Accepted by 00, `lam i�a_�.S-A.. n _ Date Area_ ) Pit or Grout Inspection byda,,,,, �...�Date Qa \1-3`1 P Final ` Inspection by ppa�..,. ter 1^L-!:17 �V Additional Comments: sfl `� L ❑ Stk 466-6181 6t! 369-362 ❑ Manteca 823-7104 01 racy 8351�1� �� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED eV DATEall-A PERMIT NO. INFO _ IN 43-24(REV. 10/8:11 38 L r. �� ^ �14 `mil ` 6 r