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fAPPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT FF 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 41, PERMIT EXPIRES 1,.YEAR..FROM,DATE ISSUE " (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 Local H made 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 Health District. J ' 0 2-4: it t , 4� 11111F W RD LO'f Job Address City StoCkton Lot Size PM Owner's Name Watanabe Bros Address 801,4 N- Alpine Road Phone 931.-3557 Contractor C'lan'k Well Address 2024 E Charter371560 �62_7b76 Wad License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES p DISPOSAL FLD.` PROP. LINE ! FOUNDATION :a AGRICULTURE WELL- ;OTHER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA_CONSTR__UCTIQN PECIFICATfONS ❑ Industrial" .❑ Open Bottom ❑ Manteca Dia. of Well Excavation J Dia. of Well-Ca ❑ Domestic/Private ❑ Gravel Pack~ w-,e.❑Tracy .. t Type of Casing - _ } M i Public + t Specifications ' r '% �f� Other + Delta Depth of Grout Seal Type of Grout ' I I Irrigation , r __Approx. Depth. -I Eastern, —Surface Seal Installed by Repair Work Done c ❑ Type of Pump H.P. - ti State Work Done _ '~ 4 Well Destruction Well Diameter; ling Material (top 50' r Depth lU er Material (Belov4w') r TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I, DESTRUCTION I I (No septic system permitted if public sewer is 1 t, Installation will serve: Residence—h hComavailable within 200 feet.) mercial— Other a Number of living units: Numbers of bedrooms Character of soil to a depth of 3 feet: '� f _ SEPTIC TANK ❑ Type/Mfg Cap acWater table depth it Y No. Compartments PKG. TREATMENT PLT- ❑ 3 : +� 1 Method of Disposal. Distance to nearest. Well z Foundation r Property Line LEACHING LINE ❑ No. & Length of lines s Total length/size FILTER BED : ❑1 Distance to nearest: Well Foundation � � Property Line SEEPAGE PITS r I i "Depth r Size Number I SUMPS L1 Distance to'nearest: Well Foundation Property Line DISPOSAL PONDS - ❑,�;- #� �j I hereby c y 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 eg lations of the Sam Joaquin Local-Health District. Home ow er r licensed agent's signature c Kies the fol wing: "I certify that in the performance of the work for which this permit is issued, I shall not employ an p son in su man eras to be a subject workman's compensation laws of California." Contractor s hiring or sub-contracting..signature certifies the o owing: " ce ify hat in rf rmance o ha work for which this permit is issued,1 shall am to tion laws of fornia.' p s ll en�p Y persons subject to workman's compensa- The appli t r a ired ins on m to dra ng on reverse side,m Signed X Title: Sec-Tres Date: 22 June 90 wn F R DEPARTMENT USE ONLY ]],,,�� Application Accepted by Date e w"�� 10 Area t Pit or Grout inspection by We r Final Inspection by DateDate Additional Comments: / y ❑ Stk 466.6781 ❑ Lodi 3621 ❑ Manteca 623-7104 ❑ Tracy 635-638 �d Applicant- Return all copies to.- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NOT elpflip FEE AMOUNT DUE AMOUNT REMITTED CK ,SIM INFO {ASH RECEIVED BY DATE PERMIT'NO. /f t.EH 13-24 IREV.I/M 51 p�/ J t0 nr