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mk APPLICATION FOR PERMIT ` - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA RSG Telephone (tag) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) A1'S Application is hereby made to the San Joaquin made Local Health District for a permit to construct and/or install the work he e'n�1dg�1�� RV1�E5 k compliance with San Joaquin County Qrdinance No. 549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Loco! Health District. ed. This application is Job Address 1804 West Main Street ii city Stockton Lot sire ' l- ' Owner's Name Bast Bay Municipal UPM�d�strict, 1804 West Main Street P� Phone 463-2463 Contractor Water Deveioprrlent 95695 �Address 220 North East St. Woc)rl I A se Ivo. C57-283326 TYPE OF WELL/PUMP: NEW WELL •--- 6 Phone 916 662-2829 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE 70 NEAREST: SEP,TIC.TANK'-* -�.... OTHER ❑ —� SEWER-L-INES . FOUNDATION 50r --�_ D_ISPO.SAL F_LD. PROP - _ . LINE 2M' -AGRICULTURE WELL �j�1 "� _ INTENDED USE OTHER WELL PITS/SUMPS - - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 2r1 I 11 Domestic/Private k� Gravel Pack Dia, of Well Casing 1 ❑ Tracy Type of Casing �� 1-1 Public n Other Specifications n Delta Depth of Gro't Seal ^- � I I lFhoation pe of fox: Depth E I Eastern Type of Grouo3M]en Repair Work Done Q T Surface Seal Installed by V(�ter Develo�rer,t Cr�r rat1011 ype of Pumpt�� H.P. —L--- _ �� State Work,Done Well Destruction ❑ Weil Diameter,: X Nfxtitori Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION ! I DESTRUCTION ! I (No septic system permitted if public sewer is Installation will serve: ResidenceCommercial Other available within 2[x1 feet.) �_ _ Number of living units: r Number of bedrooms Character of soil to a depth of 3 feet: ,1 =I SEPTIC TANK ❑ Type/Mfg `I Water table depth ' PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearest: Well I Method of Disposal I I Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size 1 I Foundation Pjr roperty Line SEEPAGE PITS 11 Depth i SUMPSWestaSize Number �. d ��r Dince to.-nea,-- rest' Well DISPOSAL PONDS_ ❑ . . ,, ` FoundationP_roe - p rty Lines �.. I hereby certify that I have'prepared this application and that the work will be done in accordance with San Joaquin ca rules and regulations of the San Joaqu*in Local Health District. Home owner or licensed agent's signature certifies the following: y q county ordinances, state laws, and employ any person in•such mariner�as to.become subject to workman's compensat compensation laws of California."Contractors hiring or sub-contracting signature F performance of the work for which this permit is issued, I shall not certifies rhe following: "I certify[fiat 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,"llowi : ..t. The applicant ust c 11 for all required inspections. Complete drawing on reverse side Signed X Title: -!Z-7 ��2- Application Accepted byDate: r ENT USE ONLY �l 57 3 i Date r Pit or Grout Inspection Date-.2: _ Final Inspection b - Additional Comments: lIklls are for r'cind voter rranitoring c Date W Stk 466-6781 ❑ Lodi 369-3621 - rLl ■ Manteca x23.7104 ❑ Tracy 835-6385 Applicant- Return al1 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA $5201 ) FEEAMOUNT DUE INFO IAMOUNT EFRIZEMITTED K RECEIVED BY DATE +-EH 13.24(REV.t i H 5l PERMIT•NO. EH 14.26 { _