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=p APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED* J� r (Complete in.Triplicate) ,. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal(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.arid the Rules and Regulations of the San Joaquin Local Health District. ys Job AddressW/SeSt__R pon 0� 35' Ft: W/O Jack Tone Rq. S oCkton .: ItY Lot Size PM Owner's Name Pacific Gas & Electric Address P.O. Box 930, Stockton 95201 Phone 942-1539 Contractor General ConStructi OnAddress 4056 E. Hwy.' 120 823-0081 License No, Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE LO r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialOpen Bottom: ❑-Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack A ❑ Tracy Type of Casing PVC Specifications ❑ Public Other $7 � jlbillG❑ Delta Depth of Grout SealT e of Grout ri ati n _ _jMpprox. Depth ID Eastern Surface Seal Installed by Pac!f c aS & Electric 0. epalr W8,Z b6n7ype of Pump N/A H.P. N/A State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Concrete Depth 120' Filler.Material (Below 501 Coke breeze 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ) available within 200 feet.) ' Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ N/A Method of Disposal w I. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines f g Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation "Pro g Property Line�. SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: , Wel! Foundation Property Line DISPOSAL PONDS ❑ nd that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application a rules and regulations of the San Joaquin Local Health District. I 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's compensation laws of California."Contractor's hiring or sub-contracting signature f 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed John Houbein" Title: Date: 1-17-86 Date: FOR ]DEPART ENT USE ONLY Application Accepted by I 6 Date ^ (J Area Pit or Grout Inspection b to Final Inspection by Date Additional Comments: e f r � ?d wi,_('�e 1 WAS D►'� 1fL(CG�'�I p/�a b d yiSq ID Silk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 Ll Tracy 835-6385 Applicant - Return all copies to: Environmental Ith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT'DUE„ AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH13-24(REV.1/95) 70 •� r (,� EH 14-26 b Q i r