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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � Telephone (209) 466-6781 1 , ftigs�a PERMIT EXPIRES I'YEAR FROM DATE ISSUED (Complete in Triplicate) ;�'t `:._��t I 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 955 White Lane city Stockton Lot Size PM Owner's Name P.D. Hunt Address Same Phone 931-0443 Contractor Clark Well Address 2024 E Charter WaYLicense No. 37_ _�6a Phone 462-7676 TYPE 6 -- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Z SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing M Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public (_I Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth" I I Eastern Surface Seal Installed by _ Repair Work Done L3 Type of Pump Stab H.P. 7/2 State Work Done Installed Well Destruction ❑ Well Diameter Sealing Material (top 501 n Depth Filler Material (Below 50'i JQ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 4 n Installation will serve: Residence} Commercial_ Other v i 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 re lations of the San Joaqbin Local Health District. Home own r 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 son in su anner as to ome ject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the owing: " ca ify that in rfor a ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawsga �tl ' The appli akuir d s do s Complete drawing on reverse side. Signed X Title: Sec—Tres Date: 5�5�89 .. '. FOR DEPARTMENT USE"ONLY `L Q Application Accepted by + date �' 1L_ 4 1 Area Pit or Grout Inspection b Data Final Inspection by / 71't Date 1&Ly . Additional Comments: ❑ Stk 466-6781 Q 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 RECEIVED BY DATE PERMiT',NO, + EH1/-2gIREV.tiKs1 I �(�IiR9"^�`-' }Or