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APPLICATION FOR PERMIT U SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA P F C E I V E Di Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM :DATE ISSUED 'AUL ' 1990 _ (Complete in Triplicate) _ Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install thew rNVI2QNME4g4 HALTS' work heretmc�q{orf t3'li"pplication 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. it Job Address City Stockton Lot Size PM San Joaquin County 222 Bast Weber Owner's Name Address `1 Phone (209 944-3675 1 ' . — Spectrum 2825 East Myrtle Avenue Contract&_ExPklration Inc. Address Stockton CA 95201 License No.C-5751,2268Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-�❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR'❑ OTHER EXSoil Borings (2) i` DISTANCE TO NEAREST: SEPTIC TANK SkEWER LINES i6 DISPOSAL FLD. PROP. LINE k 1 FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS _ • INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industria! ❑ Open Bottom 0anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public i7 Other Cl pelta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction ❑ ' Well Diameter: Sealing Material (top 50') b8Ckfill bo rin s With sand Cement to Depth Filler Material (Below 50') s11rEaCe. i' TYPE OF SEPTIC WORK: NEW INSTALLATION I ! REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if ii available within 200 feet.) public sewer is f. ' Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms ?'• Character of soil to a depth of 3 feet: ! SEPTIC TANKWater table depth PKG. TREATMENT PLT. ❑ Type/Mfg Capacity No. Compartments C1 Method of Disposal ..•, ...Distance.to nearest: W011 Foundation t Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Il Property Line I SEEPAGE PITS I ] Depth Size SUMPS 'I Number Cl Distance to nearest: Well Foundation II Property Line DISPOSAL PONDS ❑ k kt 1 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 Diktrict. Home owner or licensed agent's signature certifies the followin It employ an g: "I certify that in the performance of the work for which this permit is issued, i shall not f P y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following: '9 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 Cali •, Ali The applica mus call for all required i cti ns. Complete drawing on reverse side, i k Signed X Title: Date: 915 FOR DEPARTMENT USE ONLY s Application Accepted by i� Date Area Pit or Grout Inspection by Date Final Inspection by' i I Date Additional Comments: ; k ❑ 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., A.O. Bax 2009, Stk., CA 95201 !f Ik ii FEE AMOUNT DUE AMOUNT REMITTEbjAS K INFO [jREjCEIV�ED�13Y DATE PERMIT ND. + EH 14-26EM 13-24 1REY.r/xsl 0'7• 8/•may_,,., . i i