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IF Ilk- I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL14EALTH DISTRICT 1601 E. HAZEL` TON AVE. , -STOCKTON, CA ` Telephone (209) 466-6781IF I PERMIT EXPIRES 1- YEAR FROM DATE ISSUE. Momplete in Triplicate) = JUN 15 . 193IF Application is hereby made to the San Joaquin Local Health Districtfoca permit to construct and/or install the work herein described 7Msappfiwtiona made in compliance with San Joaquin County Ordinance No. 549 for sewage or No.:1862 for well/pump and the Rules and Regulatronsaf theappl San Joaquin IF ._ Local Health District., ;,_ - _ . . . .�' �-� J - : IF - FFF 41 ,; . ENVIRONMENTAL HEA(�'F{ t � : IF PERMIT/SERVI E� } ;� . Job Address Grant - St . . ' :A diacent 749 - - E Charteicity Stockton Lot size - pM - Owner's Name CitY of - Stockton Adde El 'Dorado ''Stvc'kton phone 944 X349 Pierson Drilling 611 S . 9th ' St _ Modest�p 6141'08 "'I IF 4�'' g3g * Fff Contractor Address L1 ense No. Phone - TYPE OF WELL/PUMP: NEW WELL - -WELL REPLACEMENi:17 . DESTRUCTION ❑ IF IP UMP 'INSTALLATION ❑ - - .SYSTEM REPAIR t 4OTHER fl Fi, Fill ' :- IF DISTANCE TO NEAREST: SEPTIC STANK , SEWER 1tNES t - .. _ - 2.0 'DISPOSAL FLD. PAOPaLINE _ x., -FOUNDATION AGRICUILTURE WELL - - OTHER WELL A— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i . IF. `§ LIF ❑ Industrial --❑ Open Bottom - ❑ Manteca -Dia. of Well Excavation Olaf, of Well rasing 2trIf I l ❑ Domssdc/Private - ❑ Srevel Pack - El Tracy I Typeof CasingPVC sch 40 S - I IF F . penficadorls ! t1 Public - fjlOther ❑ Delta Depth of Grout Seal "46 t ` '' ' +TYpe of 4irout 'Gomori t :-I I Irrigation , _ If _AI ti r_ pprox. Depth . 1. 1 Eastern ._Surface Seal Installed by Pierson ''Drilling Repair Work Done ❑ ` Typo of Pump - = H , P. FIFFIFFState Wo"one "'`� s Well Destruction D " Well Diameter Sealing Material jtop 50 1 '"Depth Filler MaterialfBelow So') FF,FFF � r TYPE OF SEPTIC WORK _ NEW INSTALLATION I ] REPAIR/ADDITION (. 1 DESTRUCTION 1 I Irvo septic system permitted if public sewer is I IF I.. I IFF `Fl . _ available ZDOicet } 1.IF I -Wi installation IF Mnll serve: " erve flmidence _ Commercial t)tller :�fr �4i f y uta 'yIF - ` z i �\ ' ;Number-of living units: _ ,Number of bedroomsIF iF , '_ s :"�fi - e I IF Character of soil to a depth of 3 feet: IF r nr. f Water table depth , . SEPTIC TANK O . '-Type/Mfg i .l Capacity. No COmpartments _ - PKG- TREATMENT PLT. ❑IF t , i , IF _ Method of DisposIF al I I- Distance to nearest: - -Well - Foundation " Property Lme *�' ' "-I c: -. c - _ 47 . - :r- _ . Ir IF 'LEACHING LINE fl 'No- & Length of linesTotal length/size i FILTER BED , ❑ Distance to nearest: d Well - Foundation - y1 I IF ,. =Property Line ' c., ddr `SEEPAGE PITS X11 Depth - Size - Number r ,<SUMPS - ❑ : Distance to nearest: Well - r ; f �` - 'foundation `- Property line - DISPOSAL PONDS 1,,, ❑ " ' ' - - ,i Ile IF If 1 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 -roles and regulations of the San Joaquin Local Health D3mct• - "Home owner or licensed agent's signature certifies the followin 1 ce - - - r IFF. - employ an 9 - rtify that in the performance of the work for which this permit n issued, I shall nut P Y y person in such manner as to become subject to workmanos compensation laws of California." ContractoYs hRing or subcont2ced, 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 - S 'Sion laws of California ,`-. _ .. ..- The applicant must call for all required inspections- Complete drawing m reverse side14 -- f. IF Signed 1L— '�'i t"t _ -' - 'fNe K �' � JP Date: ,A I J7 JL ILF FOR DEPARTMENT USE ONLY ` q� ep Y9 iIF I ! jo� IF -oa - Application Accepted b Date / Area { a1 Pit or Grout Inspection b - 3" " t y Date Final Inspection by - ` Date Additional Comments: - I - - .. - I IFfFF ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ Manteca 823-7164 - ❑ Tracy 835-6385 IF � - Apo licant - Return all copies to: Environmental Health Permit/Servitas 1601 E. Hazelton Ave. P.0- Box 2009 Stk CA 95201 IF J - FEE - AMOUNT DUE AMOUNT REMITTED CK - - INFO -Q CASH RECEIVED BV DATE PERMIY NO �. EN 1121 IREyFr 1 /8 51