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N APPLICATION FOR PERMIT ' SANG®QL11N LOCAL HEALTH DISTRICT STOCKTON , CA f Telephone (209 ) 4664'7 4&3 ' 40358 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 18 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. oar /J � - G4i3oc. t �1/ of pzO.S� Stocktgfi Ca . Job Address Area Surroun din � 749 E . Charter Waryty Stockton Lot Size PM Owner's Name Darpetrov Inc . Address 345/0� E1 Camino Ceres Ca . Phone 209 ) 537 - 077 Ee/� ir'�d�f 63 � � Vi�£ Fa6 � Sf"?j ply- 63/ - y:o Contractor - - - - " d 'ress(54 -lf - ) icense N Phone TYPE OF WELL/ PUMP: NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES 20 ' DISPOSAL FLD. PROP. LINE 10 t FOUNDATION AGRICULTURE WELL OTHER WELL 62PITS/ SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation $ Dia. of Well Casing 2 n ❑ Domestic / Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC s c h 40 Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal 46 ' Type of Grout Cement _ 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 Itop 500) Depth Filler Material ( Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR /ADDITION I I DESTRUCTIONI IND 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. ❑ Method of Disposal {^ l Distance to nearest: Well Foundation Property Line 71 LEACHING 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ (13 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 nit 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 rest ca or all fired inspections. Complete drawing on reverse side. Signed X Title: PresidentDate: 3 / 15 / 94 - - -F DEPARTMENT USE ONLY f/�� Application Accepted by Date Area 3 Pit or Grout Inspection by Date Final Inspection by 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 9 7777777771 FEE INFO AMOUNT DUE AM/OOy/(U}NTT,REMITTED �yfcAK,`R��(.y RECEIVED 9Y DATE PERMIT NO. y/ EH 13-241REV. rix5) � � .... ✓ / / �/V „(� /� �✓1. EN 14-29