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APPLICATION FOR PERMIT Y ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ;r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " (Complete in Triplicate) 1, 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. �! Job Address 911 C Thnrt- n Rnpd i City Stockton Lot Size 140'x160' PM Owner's'Name Sni thl and Corp- Address 5820 Stoner .dge'.Mall Rd.PJ:easant> 1e 415 463--2711 I Contractor Gram afar TPch.: .-ddress5047 Clayton Rd. _ _ License No. a'Sf `f _Phone 1415 671-217 TYPE OF WELL/PUMP: NEW WELL l$ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES ? DISPOSAL FLO. ? PROP. LINE 10—f t- FOUNDATION 15 ft. AGRICULTURE WELL 20O ft®THER WELL 300 ft.PITS/SUMPS 9 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R i n- Dia. of Wel! Casing CR Domestic/Private IR Gravel Pack ❑ Tracy Type of Casing DIC`. Specifications .020 in. ❑ Public j'1 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout CPmenf ❑ Irrigation N 55RApprox. Depth ❑ Eastern Surface Sea! Installed by Sierra Pacific Drilling Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wel! Diameter Sealing Material (top 501 IL Depth Filler Materia! (Below 50'1 �J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i �i 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 r [� PKG. TREATMENT PLT. E3 Method of Disposal Vd Distance to nearest: Weil Foundation Property Line .�, LEACHING LINE !! L1. No. & Length of lines Total length/size FILTER BED I, ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ii ❑ Depth Size Number SUMPS ❑ Distance to nearest: Wel! - Foundation_ Property Line DISPOSAL PONDS 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 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 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 X �"°Vw �-- Title: Project Cenl nai ct __ Date: 4=91—86 I� F P T NLY I ' Application Accepted by Date Are Pit or Grout Inspect( n (nal Inspection b ate E 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 A! FEE ,. AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH J� + EH 13-24 IREV.t i H 5} EH 1428 �S! 1