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` f ` APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT ��F-►Y tVf 1�,iti .• 1601 E. HAZEL;t ON AVE., STOCKTON, CA Tti E C E 1 V E D Telephone (249) 466-6781 PERMIT EXPIRES,.1-YEAR FROM DATE ISSUED JUL 1990 (Complete in Triplicate) _ Application is hereby made to the San Joaquin Local health District;fora rNVIRONMENTAL H ALT!-� work made in compliance with San Joaquin County Ordinance No. 549 for sewage or rNo. 1862 for cwell/dpump and he Rules and Regulations of the San Joaquin Local Health District. Job Address . City-.StOckton— Lot'Size COUIIt Sall JoaquinJoaquinPM Y 222 Rist Weber Owner's Name Address LN Spectrum2825 East M 959 2 Phone egg 944-3675 Contractor loration Inc. Address Stockton) CA fi95 02 nue License No. C-5 2 hone 2 TYPE OF WELL/PUMP; NEW WELL ❑ - WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER i$ Soil Borings (2) DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS INTENDED W USE TYPE OF ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E.❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofLWell Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack . El Tracy Type of Casing ',, Specifications [') Public F.1 Other C-1 Delta Depth:al Grout Seal _ 1 I Irrigation c -type of Grout --A pprox. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H p - State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 50') backfill borin3rS with sand ement to Depth °` surface. Filler Material f8eiow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODtTION l li DESTRUCTION I t (No septic system permitted if public sewer is Installation will serve: Residence Commercial_ Others available within 200 feet.) Number of living units: .:Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth �� PKG. TREATMENT PLT. ❑ Capacity No. Compartments Ei Method of Disposal - Distance.to nearest:, WfIl Foundation Property Line I LEACHING LINE 0 No. .A Length of lines 1; FILTER BED Total length/size ❑ Distance to nearest: Well Foundation Property Line ji SEEPAGE PITS 11 Depth Size i! SUMPS Number ❑ Distance to nearest: well Foundation DISPOSAL PONDS ❑ Property Line t, I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, and l rules and regulations of the San Joaquin Local Wealth Di§trict. 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 workma'n'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 tion laws of Cali permit is issued, 1 shall employ persons subject to workman's compensa- The applica mus call for all required i cti ns. Complete drawing on reverse side. Signed X Title: Date: i; FOR DEPARTMENT USE ONLY i Application Accepted by ' v D Q, ate Area q Pit or Grout Inspection by Data Final i fU nspectiari by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑s„Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT bUE AMOUNF REMITTED CK f .INFO ys t RECEIVED BY DATE V PE"RMIT' NO, qO R 13,24 t;�.„Ks, i EM 1..2e eq.� B / F