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APPLICATION FOR PERMIT , / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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. 1915 Navy Drive Stockton Job Address City Lot Size PM Owner's Name Carnation Can Address 1915 Navy Drive Phone 466-7077 All Terrain Contractor Exploration & Dri l l i paress 2789 Liberty Ln/Rosevi 1 l eense No.437836 Ph9 e6 771-0222 TYPE OF WELL/PUMP: NEW WELL l WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F1 SYSTEM REPAIR ❑ OTHER � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC41ITIONSL ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc;a, frn4 Dia. of Well Casing 2 inch LS Domestic/Private , Gravel Pack O Tracy Type of Casing JJ 1111 Specifications ❑ Public i Other O Delta Depth of Grout Seal 20 ft Type of Grout rpMpnt ❑ Irrigation 25_� Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done 1-1 Type of Pump nolle H.P. State Work Done Well Destruction Ll Well Diameter 2 inch Sealing Material (top 501 _f:emen_tgrnut, $entoni t2 Depth 25 feet Filler Material (Below 50') n/a TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION I I DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines _ Total length/size _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ___Size Number 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The appl' �myst call f all requir d nspections. Complete drawing on reverse side. Signed `J'- ' Title: '� Date:< <� L FOR DEPARTMENT USE ONLY v Application Accepted y /` .C_ 1 Date �— _ 7 r i Pit or Grout Inspectionbx_�_, �Date _ O final Inspection by Date Additional Comments:l/ _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 11 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. • EH 11-24IREV.i 3 J ' C) C� I I I NL) i- 747 p7—IS EH