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APPLICATION iFOR PERMIT !�. SAN JOAQUINi LOCAL HEALTH DISTRICT �. ';. 1601;E. HAZELTON`AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT.EXPIRES'1 YEAR FROM DATE ISSUED: ' y j (Complete in Triplicate) ;k • o Application is hereby made to the San Joaquin Local Health`District for a permit to construct and/or install the work hereon d ri . T ' ication is. made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rules and Rog alions of San Joaquin 7 si7 Local Health District. s � �. 2 Stockton r y Size Skton 7 000 !t• PM i Job Address 244& Ust Fremont Streei i f �� Cit Lat �. 408 245-2442 Owner's Name Jots As Nattao :Address 7.Z4ia, let Sul 3oia CA 95100 Phonal Contractor IL ilh&ugh '11011411rens s11 Dri11i 3 1676 Sladoi>t ltd.. 9!! + TA icense No4$2340 ontracto Phone (415) 683-6 13 . TYPE OF L / P: s ;I NEW WELL ❑.,ii .f � WELL;REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ k OTHER 4 'AS INSTALLATION ~ DISTANCE TO NEAREST: SEPTIC TANK 73-165' ' SEWER;LINES 35-200' DISPOSAL FLDI �` ° PROP. LINE 6� 7-127 � 1 104-144+PITS/SUMPS 22-1539 FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; ❑ Industrial ❑ Open Bottom ❑:Manteca ,, Dia.iof Well Excavation Dia. of Well Casing ❑ Domestic/Private I Gravel Pack C1,Tracy Type of Casing PVC iCit! 40 i Speeific8tions I'i Public ❑ Other Ll Delta Depth of Grout Seal 24 ft i. Type of Grout Cfnt — I I Irrigation _Approx. Depth *I Easte;:rn Surface Seal iInstalled by d a7C Repair Work Done LJ Type of Pumper y, H.P.. State Work 4one ` 11 LUCh" ; l>�a Well Destruction ❑ Well Diameter i': Sealing Material stop 50'1 Depth40 ft j Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within.200 feet.) Installation will serve: Residence_ Commercial's Other r Number of living units: Number of bedrooms , Character of soil to a depth of;13 feet: '+ r ab: v Water table depth SEPTIC TANK ❑ Type/Mfg '''° i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: li We11 Foundation Property Line LEACHING LINE D No. f3, Length of tines' I " ! Total length/size FILTER BED ❑ Distance to nearest: I 'Well '! Foundation Property Line i. SEEPAGE PITS l 1 Depth 'Size `. Number r E SUMPS f_I Distance to nearest: it Well Foundation Property Line DISPOSAL PONDS 1 7 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 iJoaquin Local Health District., j Home owner or licensed agent's signature certifies the foliowing:,; certifyL hat 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 fo workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of fhe work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ,l: The applicant must call for all required inspections. Complete drawing on "reverse side. I d- Date: 1t! ZD Signed X Title: .?.FOR DEPARTMENT USE ONLY Application Accepted by Date !/� Are Pit or Grout Inspection by ri Date ! Final Inspection by & Date Additional Comments, ! ❑ Stk 466-6781 ❑ Lodi .,369-3621 ❑`Manteca 873-7104 ❑ Tracy 835-6385 i 11 Applicant - Return all copies to:,Environmentel Health Permit/Services 1601 F. Hazelton Ave., P.O Box 2009„Stkl, CA 95201 } FEE AMOUNT DUE AMOUNT AEMITTED 5H RECEIVED BY M DATE PERMIT NO. INFO EH 142! d