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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE. , STOCKTON , CA Jldh`A"1� 1\IId1 Telephone (209) 466-6781 JUN 15 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 RGRMkTq�JBWI(3 B 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 Owner's Name Darpetro , Inc . Address 3450 El Camino Ceres Ca Phone537 - 0771 �' els 419 �66 6� Gr✓rlc °Q� -r6YH� 8' 4d6-Ay/- Contractor h Address ., 'ter- "` iwaas �ls 6 Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 40 ' DISPOSAL FLO, POOP. LINE 9 FOUNDATIONS AGRICULTURE .":ELL OTHER WELL /f9 t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 212 ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Sch 40 Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal 46 ' Typo of Grout Cement I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Pierson Dr i I Repair Work Done ❑ Type of Pump H . P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR /ADDITION I I DESTRUCTION I I (No 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 Distance to neares : well Foundation Property Line LEACHING LINE ❑ No. & Length of files Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number Wit' SUMPS 0 Distance to nearm: well Foundation Property Line 1 DISPOSAL PONDS ❑ I hereby certity 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 !-F - 1..L/ Title: yao%ae , date: 2. $ '1 3 FOR DEPARTMENT USE ONLY �I Application Accepted by // f 1 ?��K7Date Pit or Grout Inspection by Final Inspection by l 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 acwQ FEE INFO AMOUNT DUE AMOUNT/fl�EMITTED c l RECEIVED BY DATE PERMIT' ND. EN 1124 IREV. rr xs) /1 � - / f/ / 71c,2- 1 —3 y3 /yG� EH It