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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT — 1601 E. HAZELTON AVE.,:STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED • (Complete in Triplicate) 6. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de s n is made in compliance with San Joaquin County Ordinance No.549 for sewage or No 1862 for well/pump and the Rules and Regulatio Sa Jo in Local Health District. Job Address 910 Thortnn Road w City Stockton Lot Size 140'x160' PM Owner's Name Snitthl and C'r7rn_ Address 5820 Stoneridge Mall Rd.Pleasant eae(415)46 3-2 711 Contractor Crnttrtdwat-pr Ta(•h. Address50VLZ—C1Ayton_Rd- License No. 3'f Y3 Phone 1415 671-23 7 TYPE OF WELL/PUMP: NEW WELL IR WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR 1.1 OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES —1) DISPOSAL FLD. ? PROP, LINE 10 ft. FOUNDATION -15 ft. AGRICULTURE WELL 200 ftOTHER WELL 300 f t•PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial LI Open Bottom ❑ Manteca Dia. of Well Excavation_ R i n. Dia, of Well Casing IX Domestic/Private IR Gravel Pack ❑ Tracy Type of Casing—AJC Specifications .020 in. 1-1 Public (-I Other I.1 Delta Depth of Grout Seal 1.0-ft- mifty_ Type of Grout 1-1 Irrigation 55frp,pprox. Depth Il Eastern Surface Seal Installed by Sierra Pa c1f1C 111=1111 i - — Repair Work Done I I Type of Pump H.P. State,Work Done _ Well Destruction Cl Well Diameter - Sealing Material Itop 50.1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION 1-1 DESTRUCTION i 1 fNo 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 i I Type/Mfg _ Capacity �._ No. Compartments _ PKG. TREATMENT PLT. i 1 Method of Disposal Distance to nearest: Well Foundation _ Property Line -_� LEACHING LINE I I No. & Length of lines _ Total length/size_ FILTER BED Lt Distance to nearest: Well Foundation _ Property tine SEEPAGE PITS I f Depth Size _. Number SUMPS i I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I 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,I shall employ persons subject to workman's compensa- tion laws of California." —wing on nevem side, Signed X ,",x � i._ Title: PrQ JPrt- (_____Pnl n¢i St— Date: 4=91-86 „ F�:J�Ep T NLY / Application Accepted by nate . Area l3;" _ Pit or Grout Inspecti n incl Inspection by �'mate•gip�i" Additional Comments �l ❑ Stk 466.6781 ❑ Lodi 369-3511 ❑ Manteca 623-7104 ❑ Tracy 895-6305 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 13-24(REV.i i M e;r ��(� p t-1 J, _ d I ?+ S7r EH 14.2E "T7�� j .-. -] ] �.�._C� \. _ , �-�lt U ♦v Sb._Z�J� �Gr AL1. I I