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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (Complete in Triplicate) at 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 well/pump and the Rules and"Regulations of the San Joaquin Local Health District. �t `k. Job Address 2324 . Navy, Drive City Stockton Lot Size PM Owner'sNameWBSte�r State Steel Address 2324 NavyDrive Phone44-9581 fl ` Contractor's Name Clark Well. & EquipfLense Na. A--371560 Phone 462-5597 TYPE OF WELL/PUMP: NEW WELL 5J WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IR SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK. 190 SEWER LINES .,�� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I «. A,-,.INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - Yom.[J Open Bottom 11 Manteca - Dia. of Well Excavation Dia. of Well Casing 8 5 8 tt ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f Irrigation 150--Approx: Depth ❑ Eastern Surface Seal Installed by Clark-Well Repair Work Done ❑ Type of Pump Sub.._ H.P. 3 State Work Done-Install I Well Destruction ❑ Well Diameter 'Y3 Sealing Material (top 501 ,I") Depth 'r Filler Material (Below 50') S TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f available within 200 feet...) �^ Installation will serve: Residence Commercial-_ Other G Number of living units: Number of bedrooms depth Y Character of soil to a depth of 3 feet: Water table de s. p SEPTIC TANK C1 Type/Mfg:t ` Capacity No. Compartments .. - PKG. TREATMENT PLT. ❑ R°" Method of Disposal Distance to'nearest: Well Foundation Property Line i f { LEACHING LINE ❑ No. & Length•of lines Total length/size FILTER BED ❑ Distance to nearest:'—'4Well Foundation Property Line '1 i SEEPAGE PITS ❑ Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ '.I 1 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 i 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 I employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the foil ing: "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 C i rnia. - Y j The applicant t call f"re s ctions omplete drawing on reverse side. Signed Title: Sf3C—TTBS Date: 17 Jane 1985. FOR DEPARTMENT USE ONLY Application Accepted by Date Area �— Pit or Grout Inspection by Date Final inspection by Date dditional Comments: IStk 466-6781 El Lodi 369-3621 E3 Manteca 823-7104 El Tracy 8354M applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH 1324 iREV.10/83? INFO � , EH W26 !� t;