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Z. APPLICATION FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT n' a 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) �Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is Application is hereby made to the Sa made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/ and the Rules and Regulations of the San Joaquin Local Health District. City Stockton — Lot Size PM Job Address 2324 Navy Drive ' Western States steel Address 2 24 Nav Drive Stockton Phone 209 Owner's Name Roseville t 437836 Phone 91.6 771--0 -Contractor All Terrain Drillinq\ddress 2789 Liberty Lane License No. NEW WELL ❑ WELL REPLACEMENT ,O. ____ DESTRUCTION ❑ : . .- . . . TYPE OF WELL/PUMP: OTHERXVonitoring Wel PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4WC) N A SEWER LINES 50'+ DISPOSAL FLD, PROP. LINE �' +. .. DISTANCE TO NEAREST: SEPTIC TANK 20 AGRICULTURE WELL - A . .OTHER WELL FOUNDATION r N A N A PITS/SUMPS �! .. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 211 ❑ (INdustrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia at Well Casing TEND ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing PVC - Specifications r PA1 K C� Delta Depth of Grout Seal A roX 7' Type of Grout Cement k Cl Public F9 Otheri _ I I irrigation 2QApprox. Depth I I Eastern Surface Seal Installed by All Terrain Drilling Repair Work Done El Type of 1pum NONE H.P. State Work Done_ I r p Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth 'I Filler Material (Below 50') . . permi TYPE OF SEPTIC WORK: NEWT(STALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I available septic sy itt m fettled if public sewer is ' Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG.TREATMENT PLT.❑ Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ J SEEPAGE PITS I l Depth Size Number SUMPS ❑ Distance to nearest: Weil 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: "1 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."Contractors 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." r The app:7TZZ:Zi�� inspections. Complete drawing on reverse side. Signed '�� Title: roject Manager Date: Au u at- 7, 1987 ,CCIIi�� FOR DEPARTMENT USE ONLY d Data Application Accepted by Fri � Pit or Grout Inspection by Date Final Inspection by Data�13 Additional Comments: ❑ Tracy 635 6385 l Stk 466-6781 ❑ Lodi 369-3621 ❑ Id e23-7104 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 FEECK RECEIVED DATE PERMIT'NO. INFO AMDUNT DUE AMOUNT EMITTED nH /� {//� A 9W ♦ EN 13.24(REV.1/x5, t '`� � 0 U � -�[/(� EH 11-20