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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ✓ rr�h 1601 E. HAZELTON AVE. STOCKTON CA Vv� Telephone (2091466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t: Application is heteby 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. . 1 Job Address 2324 Navy Driv9 __ City Stockton Lot Size PM Owner's Name Western to Address 2324 Navy Drive x Stockton-- p _ Roseville 'Contractor All Terrain Drilling4dress-2789 Liberty Lane, License No. 437636 Phone 916 771-0 a TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT 0. _ ,DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)ttmonitoring Wel DISTANCE TO NEAREST: SEPTIC TANK - N/A _ SEWER LINES 50'+ •DISPOSAL FLO. -- PROP. LINE 75' + W I FOUNDATION 20' + AGRICULTURE WELL -M/-A--.OTHER WELL N/A PITS/SUMPS )ILA t: INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation— 8" Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pads ❑Tracy Type of Specifications n Public P4 Other PACR n Delta Depth of Grout Seal --Approx 7' Type of Grout emg11t 1 I Irrigation ?0Approx. Depth I 1 Eastern Surface Seal Installed by All Teirain_Prilling _ Repair Work Done O Type of Pump NONE H.P. State Work Done_ a Well Destruction ❑ Weil Diameter Sealing Material Itop 5(Y) ' Depth Filter Material (Below 50'1 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I? REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is f. available within 200 feet.) Installation wig serve: Residence_ Conw*rcia!_ Other Number of living units: Number of bedrooms Character of sol to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT,❑ Method of Disposal Distance to nearest: WON Foundation PropwW Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Wel Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: We" Foundation Property Line DISPOSAL PONDS ❑ 1 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 agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any Person in such manr►er as to become subject to workman's compensation laws of California."Contractors hiring a subs 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 workrnan's compenaa- tion laws of California." The applicant st can for all requirfed inspections. Complete drawing on reverse two. Signed ✓/ �+/ c Title: J Data: _ Auauni- 7. 1997 " FOR DEPARTMENT USE ONLY s Application Accepted byzu _ Date �grce 7 Pit or Grout Inspection by DateFinal tnapection by Data I J A_kconal Comments: X Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 8354.'186 Applicant- Return all copies to: Environmental Health Perrlllt/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 . FEE AMQUNT DUE AMOUNT REMITTED RECEIVED INFO DATE PERMn'NO. i I . EM,}�(REV.r,as1 ?�Z �? -3DB EH 142/