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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT I, f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I r I PERMIT EXPIRES 1'YEAR FROM DATE ISSUED } (Complete in Triplicate) is cation Application is hereby made to the a nnCoungty Ordinalnce No.549 for sewage or permit construct and/or herein Health District for a No. 1862 forwe Ilpump and the Rules and R gulations of the Sanl Joaquin made in compliance with San Joaquin f r p7 Q _ ' Local Health District. , -�.�,,e.f ,�lJ e ' city Stockt n Lat Size PM Job Address Dorado ST Phone h xowner's Name Cit of StOCkton Address 425 North El 209-944-8339 Ku_-, N fE�aF� Phone 408-275-144 Contractor E 'r CON ASSOCiateS Address 1421 Ringwood Ave San �3Q $nse No. WELL WELL ❑ REPLACEMENT ❑ DESTRUCTION 0 AWN NEW WEW TYPE OF WELL/PUMP: SYSTEM REPAIR El OTHERp• '1 PUMP INSTALLATION 4 DISr 20' 11 W-1- DISPOSAL FLD. 5O PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES 5001 PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL h � INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATION pia. of Well Casing 211 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing_ Che ll P_ 40 PVC - Specifications LD Domestic/Private Ek Gravel Pack ❑ Tracy 45 r Type of Grout Celllent�g, t Ia Other ❑ Delta Depth of Grout Seal 1 ti On i'l Public ( alled by �QApprox. Depth I 1 Eastern Surface Seal inst I I 1 Irrigation r State Work Done Repair Work Done L] Type of Pump H.P. t Sealing Material (top 501 i Well Destruction ❑ Well Diameter ��- fDepth Filler Material (Below 501 TYPE QF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTIO l I allo ptic septic m rented if public sewer is vailab t I Cfi Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Ca city No. Compartments e/Mf 4i SEPTIC TANK ❑ TYP 9 Method of Disposal f PKG. TREATMENT PLT. ❑ 1 Distance to nearest: Well F ndau Property Line Total length/size LEACHING LINE F-1 No. & Length of lines Property Line FILTER BED CIDistance to nearest: Well Foundation I ( SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: W I Foundation Prop y Line DISPOSAL PONDS Cl 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. ot 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 employ any 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: "I certify thatinthe performance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- tion laws of California." The appiic nt mus call for all required i s ctions. Complete drawing on reverse side. (( c 32� f I �. C • Title: I�C� eft YlC>L Date: II c &igned X + � �FO DEPARTMENT USE ONLY Date - Area Applica ' Accepted by 5r�.,�.�� Pit or Grout spection by Date U=0 Fina! Inspection by 1 Date I Additional Comments: ❑ Stk 468 6781 ❑ Lodi 3 -3&21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009. Stk., CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED SH INFO �7 + EH 13-24 IREV.ri n 5F .ob cu u.w