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ra . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1400 1 Ci JY�a 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES TYEAR FROM DATE ISSUED j PERI i!i,i SE-i -ES (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 j made in compliance with San Joaquin Counry Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. N! I Job Address 7971 .Ne1SOn Road City Stockton Lot Size PM t Owner's Name CONCOTE r !NC. Address 1411 W Fremont Phone 467-4111 Contractor Clark lWell Address 2024 E Charter Way License No,_3Z1,560 Phone 462-7676 q TYPE OF WELL/PUMP;: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION 1K SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { r ❑ Industrial ..f❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private 4-❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public # ❑ Other �� ❑ Delta Depth of Grout Seal Type of Grout _ I i Irrigation _-Approx'Depth I i Eastern Surface Seal Installed by __Clark Well Repair Work Done ❑, "T pr p Type of Pump'SU}J `Ii:Pc_2HP State Work Done-Ins ta11ed Well Destruction ❑ Welt Diameter: Sealing Material (top 501 Depth Filler Material (Below 50'1 f TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 R AIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ; T t available within 200 feet.) ¢jlrI staitation will serve,'—,Residence _Commercial— Other Number of.living uniis: Number of bedrooms ;Character of soil w� to a depth of 3 feet:T Water table depth d SEPTIC TANKI I❑ Type/Mfg '"- # Capacity No. Compartments PKG. TREATMENT PLT. ❑ s Method of Disposal Distance-to""n`e'arest:— Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines `Total length/size a FILTER BED ; ❑ Distance to nearest: " Well Foundation Property Line ] I F SEEPAGE PITS 1-1 Depth Size ` Number SUMPS j L1 Distance to nearest: Well" Foundation Property Line DISPOSAL PONDS 4' ❑ I . 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 perforfnance of the work for which this permit is issued, I shall not empioy_any,, r on-in.such-mannet_as.to-become-subject.to-workman:s-.compensation,laws•ofXalifornia. -Contractor's hiring or sub-contracting signature certifies the II iAg ' 4a; work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of at or The applica se drawing on reverse side. Signed X 0* Title: S e c-Tre S Date: _ Z`+NOV 88 FOR DEPARTMENT USE ONLYe Application Accepted by / r r .Date +"`- V Area r I Pit or Grout Inspection by ' Date Final Inspection by Date%-o-)g`yk d Additional Comments: ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i INFO AMOUNT DUAMOUN fiEMITTED CASH RECEIVED BY DATE PERMIT"NO. +.EH 13.24 IREV.1/115) �� ` ' EH 14-28 �7