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APPLICATION FOR PERMIT PA :- SAN JOAQUIN LOCAL HEALTH DISTRICT .R YM 1601 E. HAZEL T ON AVE., STOCKTON, CA CFI V�xD Telephone (209) 466-6781 APR 2 0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f/VV'R ��b�'� (Complete in Triplicate) P RN�M7-ENrAL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descrRf� i 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 thA Joa�in Local Health District. Job Address 2324 Nav Drive City Stockton Lot Size PM _ Owner's Name PDM S roca 1 Address Phone 2324 Navy Drive 209-948-4672 _ Contractor SCS En ineers Ad 61 Sierra Ct._ "D" License No. _ Phone415-829-0661 TYPE OF WELL/PUMP WELL ❑ WELL REPLACEMENT E-1 DESTRUCTION ❑ P INSTALLATION SYSTEM REPAIR ❑ OTHER El DISTANCE TO NE T. SEPTIC TANK 5EW L ES - DISPOSAL FLD. - PROP. LINE - FOUNDATIO 25 I AGRICUL AE WELL - OTHER WELL 12 11 PITS/SUMPS-_ INTENDED USE TYPE OF ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L Industrial T ❑ Open ottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ ❑ Domestic/Private ❑ Grave Pack ❑ Tracy Type of Casing - Specifications 7 Public EX Other ❑ Delta Depth Grout Seal - Type of Grout_ - Li Irrigation __ App x. Depth Cl Eastern Surface Se Installed by - Repair Work Done ❑ Type of Pu H.P. State Work Done Well Destruction ❑ Well Diameter _ w Sealing Materia top 50') Depth Filler Mater (Below 501 u TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A TION ❑ DESTRUCTION 171 INo 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 11 Type/Mfg Capaci No. Compartments PKG. TREATMENT PLT. [I Method of Disposal Distance to nearest: Well Foun aTion Pr rty Line LEACHING LINE ❑ No. & Length of lines Total len h/size FILTER BED ❑ Distance to nearest: Well Foundation roperty Line rs■^r SEEPAGE PITS 0 Depth Size Number M SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS U 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 cert 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." Th li nt r all required ' i s- Complete draqingoverse side. 5i a T ' - " Date: FOR DENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by -^ Date _ Additional Comments: ❑ 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-NO. + EH 13-24 1REV,1,85) EH 11-26