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r ' L„ =' V APPLICATION FOR PERMIT SAN JOAQU'iN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.73-3 6 S Telephone (209) 466-6781 S 7 PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Jo aquin-Lccal 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. Job Address 6011 West Lane — Stockton Subdivision Name NIA Owner's Name Jesters Club -. Address 6011 West Lane — Stockton Phone —47a-9991T Contractor's NaneValley Mechanical, Inclicense No. 333319 A) Phone 93.14Q3.1 + TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION YJ W PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ ! ' DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES 30r—O,, DISPOSAL FLD. N/A PROP, LINE FOUNDATION 431-011 AGRICULTURE WELL N �, OTHER WELL N/A PITS/SUMPS N/A `�- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION'S I Industrial U Open Bottom Manteca Dia. of Well Excavation y LJ Domestic/Private 7 Gravel Pack Tracy Dia. of Well Casing 17 Public LJ Other Delta irrigation Type of Casing LI 9 Approx. Eastern Specifications ❑ Cathodic Protection Depth p Geophysical Depth of Grout Seal U Other . Type of Grout Surface Seal Installed by e it ork D ne pe of Pump H.P. State Work Done s ruc i n l,Diameter Sealing Material (top 50') 0 pth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LIJ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments TF4EENF�PL7.� pe/Mfg-7. Capacity Method of Disposal SEWAGE SYSTEM ERD'stance to nearest: Well N/A Foundation 10'—Orr Property Line R5+—Or, DESTR TION - LEACHING LINE No. & Length of lines Total length/size Distance to nearest: Well Foundation Property Line SEEPAGE PITS CI Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line 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 compensation laws of California.” Contractor's hiring or sub-c ntracting signature certifies the following: "I certify that in the performance of the work for which this permit issued, 1 sh I emp oy persons subject to workman's compensation laws of California." The appy ant st call al fired inspections. Complete drawing on reverse side. Signed Title: V_Z� to — -- Date: 5/16/83_ FOR,DEPART DN Application Accepted y Area �� 'Stk 466-6781 Additional Comments Lodi 369-3621 t, Loe; Inspection by Date Manteca 823-7104 S T iaaa nspection by L� _ - Date J� �6 �[f L� Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT -DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO _ EH 13-24 REV: 1O/82 10/82 500 14-26 f