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APPLICATION FOR PERMIT , 1 I. SAN JOAQUIN '9 LOCAL HEALTH DISTRICT g ` + 1601 E. HAZEL,T ON AVE,, STOCKTON, CA I. y • TeIephQrte {2€9) 466-6781 FEB 2 ': 199 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED �• - (Complete in Triplicate) 'wrr,n.«.. EN'FAL,HFA!t. .. 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 welt/pump and the Flutes and Regulations of the San Joaquin Local Health District. I !' Job Address 110 W?st Sonora SL-r—i- City�Stockton Lot Size . PM Owner's Name Ctr of Stexktttet lit—of _ Address City Hall Stt�c2C1 •-1997 Phone . IJ Address ; '� t: u,-� License No._467252 Phone 2()9-x+65-•8712 Ctsntractor y - .��.;.�.,.,�...�_y..:...��t is TYPE OF WELL/PUMP: NEW WELL.N� WELL REPLACEMENT 0 DESTRUCTION I ,- PUMP INSTALLATION Cl SYSTEM REPAIR © ttTHER-D DISTANCE TO NEAREST: SEPTIC TANK 110ne SEWER LINES , D1sPOSAL FLO. PROP, LINE QDt FOUNDATION � r AGRICULTURE WELL OTHER WELL_1500!_._ PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- rr El Industrial 0 Open Bottom E l Manteca Dia. of Weil Excavation, Dia. of Well Casing Domestic/Private D Gravel Pack Cl Tracy Type of Casing Specifications x C'I Public tfX Other Mor6tor ngf l Delta Depth of.Grout seal 35 ... Type of Grout bettt xtt to I' I I Irrigation —Approx. Depth I.I Eastern Surface seal Installed by Ajjj6Q4=DrilliM Repair Work [lone 13 Type of Pump � N.P." State Work Done_ i,. Well Destruction ` 0 Well Diameter 8 itches Sealing Material(top 5W01 irrOlut Filler Material (Below 50`} �Xi x Other Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION I"i REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is availablewithin200 feet.) Installation will serve: Residence— Commercial— Other — ` yt-• Number of living units. . Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTICTANK O Type/Mfg Capacity No. Compartments PKC.TREATMENT PLT. ( Method of Disposal ' Distance to-nearest: Well Foundation- Property Line LEACHING LINE LI No. & Length of lines Total length/size FILTER BED 0 Distance to pearest: Well Foundation Property Lina I SEEPAGE PITS 11. Depth Size Number t SUMPS 0 Distance to.nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ k.: l 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. z 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 compansa- ::, tion laws of California." t ' The applicant mu 1" for alAeqed inspections. Complete drawing on reverse side. t71eCt GeolO>gist SData: 2—$-90 igned Title: Applied System, 4191 Rd., agmt for City of Stocks l FOR DEPARTMENT USE ONLY k Application<Accepted by " Data Area rPit or Grout Inspection by Date Final Inspection by Date Additional Comments:. E:1 Stk 466-6781 O Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E„Hazalton Ave., P.O?. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT yREMITTEd' ''t..CAS+i RECEIVED 8Y DATE PERMIT'NO. s ; INFO. EH t3-20/REV:t 1 x s! •'fes e Q ¢} EH 14-25