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APPLICATION FOR PERMIT 1 aAN JOAQUIN LOCAL HEALTH DISTR , . I STOCKTON CA Telephone (209) 468-6987 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. 1862 for well / pump and the Rules and Regulations of the San Joaquin Local Health District,710 Job Address 9 �North El Dorado Street c;ty Stoclbm Lot Size PM Owner's Name fiProducts Cmipar , Address P'0' BOX 5811, �� 58117 t Gk .� Phone 415 —2434 n, Contractor " 72" Address P•0• BOX 726, Lirloolnt CA License No- 63+3 Phone 916 6+5-9355 TYPE OF WELL/ PUMP: NEW WELL )M WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIOI�LD ft SYSTEM RE ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK >7J EWER LINES ft - 1-DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL `OTHER WELL N'� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation irrh Dia. of Well Casing 4 ❑ Domestic/ Private El Gravel Pack ❑ Tracy Type of Casing Specifications f`I Public P.9 Other n Delta Depth of Grout Seal 60 Type of Grout mba-l� I I Irrigation 75 Approx. Depth l I Eastern Surface Seal Installed by Driller _ Repair Work Done ❑ Type of Pump H . P. State Work Done Well Destruction ❑ Well Diameter 4 irich Sealing Material (top 50') 91put ter Mz1i-tL'th 75 flet Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR /ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is it available within 200 feet. ) \ Installation will serve: Residence _ Commercial _ lk*45. Number of living units: _ Number of bedrooms P Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg N PI+ No. Compartments PKG . TREATMENT PLT. ❑ _ 4 t �`t Method of Disposal Distance to nearest: Well F � C erty Line LEACHING LINE ❑ No. & Length of lines leng FILTER BED ❑ Distance to nearest; Well Foundation1ny Line SEEPAGE PITS I I Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 not 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." fThe applicant st all tar all required inspections. pComplete drawing on reverse side. c Signed X I� I f . y � e46 Title: Proiect 2r Date: (0/N � � 2— Ridlard H. WallS FOR DEPARTMENT USE ONLY Application Accepted by / Date C Area L c� Pit or Grout Inspection by / D tern9 C Final Inspection>by�--/�� Date Additional Comments: .SP A6 / C ❑ 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 952dPERMIT* NO. FEE AMOUNT DUEAMOUNT REMITTED RECEIVED BV DATE NOEH 13-24 (RM 1 / R5) EH 14 2a (+ L