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APPLICATION FOR PERMIT �J SV ► - SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKT ON, CA Telephone (209)_.466-6781 P�11'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED h1 f C ate in Triplica1 E vs NM v �{1C pp rryil` � $' 'ttt� � q . A ficatio' the San Joa uin Local W District for aperuct and/or install the work herein described. This application is made m compliant�e ith San Joaquin County Ordi ce No.549 for sewage or well/pump and the Rulas and Regulations of the San Joaquin Local Health District. Job Address 1665 Pacific venuetockto Lot Size 110'x130' PM 175 IN, UNOCAL rpration WalnutCA 94596• (415)945-7676 Owner's Name r Address Phone Contractor Datu xploration Address 430 Evora . ,Pittsburg,LiMse No.480802 Phone (415)682-5560 i TYPE OF W /PUMP: NEW WELL PI W L REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ I DISTANCE TO NEARLST: SEPTIC TANK SEWE LINES $0, DISPOSAL FLD. PROP. LINE 35' j FOUNDATION ^i 20 AG CULTURE WELL OTHER WELL1000' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEPdAREA CONSTRUCTION .SPECIFICATIONS El Industrial ❑ Open Bottom 1-1 Maofeca Dia. of Well Excavation Dia. of Well Casing 211 Schd 40 ❑ Domestic/Private fl Gravel Pack ❑ T acy Type of Casing PVC Specifications I f1 Public Pq Other Monitor elta Depth of Grout Seat 25 Type of Grout Neat cement I I Irrigation 50-Approx. Dep'F I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump iiiii 0A Repair H,P. State Work Do _ Well Destruction ❑ Well Diameter 2" Sealing Material (top 50'1 Neat ce t Depth .1 0' Filler Material (Below 501) TYPE OF SEPTIC WORK; NEW INSTAL TION 1.1 REPAIR/ADDITION I I DEST TION I I (No septic system per tted if public sewer is available within 200 et.) Installation will serve: Residence Commercial— Other Number of living units: N der of bedrooms Character of soil to a depth of 3 et: Ware table depth SEPTIC TANK ❑ Typ /Mfg' Capacity N . Compartments PKG. TREATMENT PLT. ❑ ethod of Disposal Di tante to neares Well Foundation Pr party Line LEACHING LINE ❑ No. & Length of lines To length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line ? 1 -.- SEEPAGE PITS i=1 'Depth Size Number SUMPS Cl Dista[1ce to nearest: Well Foundati Property Line DISPOSAL-PONDS ❑ I hereby certify that I have prepared this application and that the work will b done in accordance with San Joaquin county ordinances, state laws, and j. rules and regulations of the San Joaquin Local Health District. Home owner or.licensed agent's signature certifies the following: "I certif that in the performance of the work for which this erfnitls-issued, I shall not employ any,parson.in succi imanriWiis.to become subject to workman's mpensation laws of California." Contractor' i g or sub-contr cling signature l certifies the following: "I certify+tlj4!7K_the performance of the work for hich this permit is issued, I shall emplo rsons subject to wor an compensa- tion laws of California." € I The applicant must call for all required inspections. Complete dra Ing on reverse side. Signed x T le: Staff Geol 'st Date: 5/5/88 FOR DEPARTMENT USE ONLY Application Accepted by Date S Z�L�a' Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601:E. Hazelton Ave., P.O. Box 2009, Stk.,�CA 95201 t FEEi INFO AMOUNT DUE' AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. + EH13-24[REV.I i H 5) EH 14-26 ►_ An t,ri, 1