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i 1 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) i pplication 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. y� Irr� HAMMER LANE ' STOCKTON L, �;�s PM Job Address.%, "' 'of City Watanabe Bros. 80 .4 N. Alpine Road Phone 931-355'7 Owner's Name Address S' Contractor Clark We 11',', Address 2024 E Charter Way License No. 37 ..560 !Phone 462-7676 TYPE OF WELL/PUMP: 11 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION X t 1 PUMP INSTALLATION El REPAIR ❑ OTHER 17 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ° PROP. LINE FOUNDATION AGRICULTURE WELL: "' ? OTHER WELL '; PITS/SUMPS INTENDED USE — TYPE OF,WFLL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS r 1 ❑ Industrial ❑ Open,Bottom ❑ Manteca tdti Dia`of Well Excavation Dia. of Well Casing q vw ❑ Domestic/Private ❑ Gravel Pack '❑ TracywJ' t Type of Casing ' "' Specifications, /Cj ► r'] Public L1 Other ❑ Delta Depth of Grout Seal 1 Type of Grout—.--., l I i irrigation �nApprox. Depth I I Eastern. Surface Seal Installed by C Repair Work Done LJ Type of Pump H.P. State WorkFDone h " .SO Cement Grout Weil Destruction 1 Well Diameter Baling Material Stop 50'1 Depth 1V Filler Material (Below/50') — p TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR/ADDITION i I DESTRUCTION f I (No septic system permitted'if public sewer is available within 200 feet.) A r Installation will serve: Residence Commercial —` Other . *}�' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity r< No. Compartments' I 'ti b Method of Disposal PKG. TREATMENT PLT. ❑ J,' Distance to nearest: Weil,— Foundation f Property Line I len Total% th/size t LEACHING LINE 17-1 No. & Length of lines 9 FILTER BED E3 Distance to nearest: Well Foundation r r, Property Line SEEPAGE PITS { I Depth Size Number I �_ SUMPS ❑ i Distance to nearest: Well, Foundation Property Line k 1k DISPOS P NDS ❑ t # I hereby certif that I ha spared application and th the work will be done in accordance with San Joaquin county ordinances, state laws, and t rules an regul tions of he an Joaquin Loc I Health Dis ri t. . Home o ner o license age 's si natu fes the fol: ing: "I certify that in the performance of the work for which this permit is issued, I shall not employ a pe on,in s h m ne as b subject orkman's compensation laws of.California.:'.Contractor's hiring or sub contracting signature certifies ih ing:."I ertif t tin he rf mance o a e work for which this permit is issued, I shall employ persons subject to workman's compensa i. tion laws of a fornia." 7. t The ap ice st i ins o C to drawing on reverse side. Signed I Title: Sec--Tres Date: 22 `Tune 90 OR DEPARTMENT USE ONLY APP P Y lication Accepted b Date � 074! _ Area �`/1/ y - Pit or Grout Inspection by Date Final Inspection by Date' ? D Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 s CJ FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. p1"39� INFO L +.EH 13.241REV.1/95Y 310 EH 14-28 J