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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE. , STOCKTON , CA Telephone (209) 466-6781 PERMIT EXPIRES 1 * YEAR FROM DATE ISSUE . mm (Complete in Triplicate ) JUN 1 51199 Application is heieby made to the San Joaquin Kcal Health District for-a permit to construct and/or install the work herein descrfieA. 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 Regulat;onsof the San Joaquin Local Health District., _ tr .k :Q ENVIRONMENTAL.HEAUi , -_ PERMIT/SERVICES Joh Address Grant St . , - Ad latent 749 E . Charte >c;ty StocktonLot Size =PM - _. - ownersName City of ` Stockton AddreEl ' Doaado Sto4ckt.on Phone "944'=$349 r�nF U�r.;� 3 o, c r a �a r� s'IQSIz$ s ;;�J(a;6 Contracto Address I ansa No. Phone TYPE OF WELL/PUMP: . NEW WELL - -WELL REPLACEMENT ❑ DESTRUCTION - - ;"PUMP 'INSTALLATION ❑ -,SYSTEM REPAIR ❑ -4aTHER ❑ - DISTANCETONEAREST: SEPTIC :TANK SEWER LINES '�C) -DISPOSAL FLD. PROP. LINE JQ!L.i_ FOUNDATION AGP,ICULT'RE WEL! - OT4ER :^JELL- § a t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS "" ❑ Industrial -❑ Open Bottom ❑ Manteca _ , Dia. .nf Well Excavation Dia. of Well CaW 2 't -❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing VC SCh 40 Specifications . A t �L (1 Public ❑Other - ❑ Delta -Depth of Grout Seal `4' b - - Type of Groin Cement - I I - Irrigation _Approx, Depth I I Eastern "- Surface Seat Installed by Pierson ��'Dril7in - 'Repair Work Done ❑ Type of Pump H.P. ` - State Work. Dorte - Well Destruction D Well Diameter - , SwungMaterialItop -50'1 - - - - ,`Depthfiller Material (Below 50') TYOEPTIC WORK NEW INSTALLATION II REPAIR/ADDITION l I DESTRUCTION I I (No septic —system permmed if public sewer is - ,. 1. evadable welt n 200 tuet ] ' -� j t C Installation well server Com_ Comerclal Other - 't - �3* Number of living units: _ ":Number of bedrooms Im - - PFa Character of sail to a depth of 3 feet: - 'Water table - '' depth SEPTIC TANK - ❑ Type/Mfg - Capacity. No. Compartments _ PKG. TREATMENT PLT. ❑ - - _ _ Method of Disposal `Distance to nearest -Well Foundation — Property tine lam, em LEACHING LINE ❑ No. & Length of Ines " ' - Total length/size mr - FILTER BED - ❑ Distance to nearest Well - Foundation 'Property Line ttt; - - ' SEEPAGE PITS 11 Depth Size Number -- - -"SUMPS ❑ Distance to neaistt Well "foundation Property Line y a, - DISPOSAL PONDS --1 ❑ --" - - - - - - - } y-- 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 G rules and regulations of the San Joaquin Local Health D3trict. - 'Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is sued, 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 S certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman s compensa- ` - -tion lam of California." _ - ,•„_.: The applicant must call for all required inspections Complete drawing on reverse side. . J - Signed X�� - . Title: ' y PAa I12 7 AA- At-:x) A4 BJP Date t ' � _ FOR DEPARTMENT USE ONLY Application Accepted by m Date / Pit or Grout Inspection by /� c Date mom , 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 95201FEE (� INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT N0. .. EH 1a-241 (REV. mi a al . . n q " U ��1 �'� EH 142a