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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 _ E R FROM DATE ISSUED SANjOAQ�ctRm+ "!!,i �DNIS mplete in Triplicate) FEB 0 1 199Q MMONMENY'� Application is here y ma hem Sin a t s nct for a permit to construct and/or install the woew sc,Cgybed. This application is made in compliance t o n�r� for sewage or'No. 1862 for well/pump and the Rules ar t�+,Waf 1t�e,C Iwioaquin Local Health District l I Job Address 440 WestLhart��... city Stockton Lot Size 200'-150' PM Texaco Refining and 10 Universal City Plaza 'i1 Universal Cit Phone 818 MarlrAi 5 5— Owner's Name •• i n�,—Inr• Address Groundwater. SiC�'�"'1 1401 Halyard Dr. , Suite 140 Contractor TeChnCFlogy;N IriC. Address West Sacramento, Ca. License No. 434343 Phone X916 372-47 TYPE OF WELL/PUMP: NEW WELL I& WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E�r-/9 L✓ ' �j �j DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES DISPOSAL FLD. PROP. LINE F. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial L' pen Bottom ❑ Manteca Dia. of Well Excavation 10.5" Dia. of Well Casing 11 ❑ Domestic/Private ❑Gravel Pack LJTracy Type of Casing PVC Specifications �- M IPublic Cl�Other Cl Delta Depth of Grout Seal ? Type of Grout Neat Cemerit_. \� I I Irrigation J ..Approx. Depth i 1 Eastern Surface Seal Installed by Contractor �\ Repair Work Done ❑ Type of Pump - H.P. State Work Done 4 Well Destruction ❑ Well Diameter 10.5'r Sealing Material (top 501 'Bentonite and Npat. Cernent. f x-Monitoring Well Depth 45' Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR IADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Ili available within 200 feet) Installation will serve: Residence_ Commercial— Other Number of living units: II Number of bedrooms I 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 01 No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS I I Depth Size Number SUMPS ❑' 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 Di?;trict. 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contfacting 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." I!� The applicant plust 11 far all re uir d instion . Complete drawing on reverse side. Signed X' IF Title: eoloaist/Site supervisor_ Date: �I �EPA12 NT USE ONLY ' I Application Accepted by Date J G' Area J 2d l Pit or Grout Inspection by `;i. Data Final Inspection b Date Additional Comments: !III ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copiesito: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.95201 i I�. FEE AMdUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH14-Zd 3-24(FIEV.t/N5] EH 1 I illi