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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �a rR 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephohe (209) 466-6781 NOV 2 B 19En)9 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL FIE-ALTH �...�.�...r �....„ ., .., (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District lot a pinnin 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. Job Address ��,Z.l] East Victor Road City L911 Lot Size pM Owner's Name Overhead Door Corp. Address 1 220 East Victor Road .__ Phong209-334-4800 .I 5729 f Sonoma Dr. DrilliI�g Contractor BSK and ASSOciateAddressPleaeantnn C-. 94S"License No.42U_q_9_y—Phone 41 5-469-400 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Environmental PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHEROil borings DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR P. LINE FOUNDATION t- AGRICULTURE WELL ^ OTHER WELL Of— PITS/SUMPS �_— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications 1-1 Public ❑ Other fl Delta Depth of Grout Seal -_� Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by IS-E& Repair Work Done ❑ Type of Pump _ H.P. State Work Done _ Well Destruction ❑ Well Diameter" Sealing Material (top 50'1 Depth Filler Material f8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I ll>akeptic system permitted if public sewer is N le within 200 feet.) `) Installation will serve: Residence_ Commercial_ Other (r "/� )/ Number of living units: _ Number of bedrooms NCharacter of soil to a depth of 3 feet: /y SEPTIC TANK 0 Type/Mfg Capacity No. C partmen I`' PKG. TREATMENT PLT. ❑ Method of Disp 1 t Distance to nearest Well Foundation Properly Line LEACHING LINE ❑ No. 8 Length of lines Total length/size _ FILTER BED CI Distance to nearest: Well _ Foundation __ Property Line SEEPAGE PITS I I Depth _Size _ Number y SUMPS IT Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I1 q I hereby candy that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and Al rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature candies the following: "I cavity 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 candies the following: "(comfy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa lion laws of California." The applicant all for to quired ins coons. —omplQte`drawing on reverse side. Signed )(_/�/ LI'�'^ Title: F011 DVAfiI.iMENT USE ONLY Application Accepted by �'+ _ ._ Dow �! Area Pit or Grout Inspection 6y Datn . -y If Final Inspection Uy�' Additional Comments IM �i3T x(if /h.01 /L` ❑ Sik 466-6781 ❑ Lodi 369 1 ❑ Manteca 823-7104 -❑ Tracy a35.Fi385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazolton Ave., P.O. Bo. 2009, Sik., CA 95201 y FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PEHMI7'NO. 5(/_1o2/ NFOCA, • ER 13-34(REV.i,.SI ENa-te �.�_� �Ou �L-f