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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 isherebymade 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. Jab Address H4zel ton. Ave_.: 125:'- E/0 Stanisl aus city Stockton ' Lot Size PM Pacific i:c Gay & El ectric P.i.O. Bo-X-930 - Stockton 95201 942-1539 ' Owner's Name Address Phone General Constructi,o . 4055 E'. Hwy 120 823-0081 Contractor lAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 14' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial )(IOpen Bottom L1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ac Specifications I, ❑ Public A Other C19TNoaK-' ❑ Delta Depth of Grout Seal 87k'.— Type of Grout is Gas= & Electric Co. ❑�+y-Irri ation pprox. Depth El Eastern Surface Seal Installed by.�cif� Rgp 1 n keype- f Pump _ H.P. N/}� State Work Dane Well Destruction ❑ Well Diameter 0� Sealing Material (top 50') f'Oncrete. Depth 120Filler Material (Below 50') r.()kcm Breeze TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.i 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LJN/A Method of Disposal Distance to nearest: Well Foundation Property Line 1 II LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED C1 .Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ ' Depth Size Number SUMPS ❑. Distance to nearest: . Well Foundation Property Line ' DISPOSAL PONDS ❑ E 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 .a 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." C The applicant must call for all required inspections. Complete drawing on reverse side. l *• En i,nee.r-Esa�matar � 1-1786 Signed John Hoube�.n Title: � Date: FOR DEP TMENT USE ONLY Application Accepted by CN Date F / —&Area Pit or Grout Inspection by Date Final Inspection by Date Ad itional Comments: 466-6781 IDLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Apph ant- Return all copies to: Envirorimental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t tFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 13Y DATE PERMIT'NO. { Cw INFO d y EH 13-24(REV. 5) Aa --' Y�t,p gb ��o-+ys , EH 14-26 - - I