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9 ki I 611 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 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. 549 for sewage or No. 1862 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District.' 1-5, Ad./- 2190 N. JackTone Road- Stncktnn _ CA- r-:.., I — 0:,e ORA Owner's Name Jesse Becerra Address 2190 N. JackTone Road,_ Stkn, Phone478-2987 Contractor's Name . Jerry JQY & ASSOciate$icense No. 394241 _ Phone462-1481 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 RECEIVED BY PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD k PROP. LINE $45.00 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy "Type of Casing <Specifications 0 Public © Other ❑ Delta `Depth of Grout Seal Type of Grout ❑ Irrigation _— Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ .Type of Pump H. P. State War Done ` Well Destruction 0 Well Diameter Sealing Material (top 50') Depth - Filler Material (Below SO') TYPE OF SEPTIC WORK: NEW INSTALLATION ® REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _X._ Commercial— Other " Number of living units: 1 Number of bedrooms 3 Character of soil to a depth of 3 feet: adobe Water table depth r .+ SEPTIC TANK [9 Type/Mfg _ Concrete Capacity_ 12QQ- No. Compartments NO PKG. TREATMENT PLT. ❑ Method of Disposal sedimentation Distance to nearest: Well 1251+ Foundation 20 Property Line 80 LEACHING LINE [XI No. & Length of lines —Two -. 851 Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation ._. 0 Property Line 80 SEEPAGE PITS IN Depth 25 size ' 331i Number _ ltrSX- SUMPS ❑ Distance to nearest: Well 1501+ Foundation 100 t + Property Line 80 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." 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 shalt employ persons subject to workman's compensa- tion laws of California." The applicant'must call fo all required inspe tions. Complete drawing on reverse side. Sig J rr Joy Title: President Date: Sept. 4, 1984 _ r FOR DEPARTMENT USE ONLY Application Accepted by p G Data �� L'�g Area Pit or Grout Inspection by ate L o Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i .Ek 13-24 (REV. 101831 Eh 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. $45.00 coS 1C=X -j37 9 0 1