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APPLICATION FOR PERMIT p&gIvEg SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE. , STOCKTON, CA Telephone (209) 466-6781 JUN 1 5 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work PERM QERMION 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 749 E . Charter Way , City Stockton Lot Size 1 / 3 Acre PM Owners Name Darpetro , Inc . Address 3450 E1 Camino , Ceres , CaPhone537 - 0771 Contractor Pierson Drilling; Address 6115 . 9th St . ModestQanse.Xta. 614108 Phone 545 - 2838 TYPE OF WELL/ PUMP: NEW WELL 4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 40 ' DISPOSAL FLD. PROP. LINES FOUNDATION =T AGRICULTURE `.:'ELL OTHER WELL 9 r _ PITS/ SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 211 ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC SCh 40 Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal 46 ' p Type of Grout C e m e n t I I Irrigation —. Approx. Depth I I Eastern Surface Seal Installed by Pierson Drilling Repair Work Done ❑ Type of Pump H . P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material ( Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR /ADDITION 1 I DESTRUCTION I I ( No septic system permitted if public sewer is available within 200 feet. ) Installation will serve: Residence _ Commercial _ Other s (� 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 0 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 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 D13trict. 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. " 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. " The applicant must call for all required inspections. Complete drawing on reverse side. Signed X X R - , Vy Title: N paByee ' , Jou .4 Date: ,, FOR DEPARTMENT USE ONLY Application Accepted by ' r � LCA Date Area Z Pit or Grout Inspection by Date 3 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E- Hazelton Ave., P. O. Box 2009, Stk., CA 95201 agooFEE 'I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITLNO. . EH I121 IREV. 1r85) -3 EH 11-28