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APPLICATION FOR PERMIT M Z7 F SAN JOAQUIN LOCAL HEALTH DISTRICT Z 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1'YEAR FROM -DATE ISSUED "v!i;C1^1 �''EyiNE (Complete in Triplicate) r.7r-,N.;'. fication is No. 549 for sewage r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin oaquin Local District for a permit to construct Application is hereby made to the San J and/or install the work herein described.This app made in compliance with San Joaquin County ordinance Local Health District. ' Lot Size PM City Job Address 800 West Churc re2©g 466-5251 Products $00 West Church St. Stockton Phone Gold Bond Building Address 6 Owner's Name Rancho .Cordova 9428 _Phone( 6 B&F Drill Inc. Address 3663 Omec Circle, License No.�� Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ NEW WELL ❑ OTHER 15 boreholes TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION ❑. P1T:51SUMPS- SEWER LINES ��--- DISPOSAL FLD. PROP. LINE ` DISTANCE TO NEAREST: SEPTIC TANK ..�_-- OTHER-WELL. - _ FOUNDATION —_—=-- AGRICULTU_ RE WELL ��-- Typf pF WELL PROSL� ARA CONSTRUCTION SPECIFICATIONS Dia. 01 Well Casing INTENDED USE D-*Ia— n . of Well Excavation a ❑ Open Bottom MantecaSpecifications ❑ industrial Delta dType of Casing ❑ Gravel Pack Type of Grout e I-) Domestic/Private ❑ Tracy C1 epth of Grout Seal r Public (X Other rax. Depth I 1 Eastern Surface Seal Installed by t I Irrigation 10 ft-14 ft kpp H.P. State Work Done — Repair Work Done ❑ Type of Pump -- Sealing Material Stop 501 Well Destruction ❑ Well Diameter ` Depth Filler Material (Below 50'I available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 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: Capacity_ -- . No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG, TREATMENT PLT.❑ Foundatioh��— Property.Line Distance to nearest: Well Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER HED ❑ Distance to nearest: Well Foundation—�-- Number I Depth Size ----- SEEPAGE PITS Foundation Property Line SUMPS L Distance to nearest: Well :. _, .�_• -_ t DISPOSAL PONDS ❑ x 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, andT rules and regulations of the San Joaquin Local Health District. I certify that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signature certifies the following: " y arsons subject to workman's compensa E employ any parson in such manners s o become subject a of the workman's k for which compensation Permitws issued, shall amploty Contractor's hiring or sub contracting signature certifies the following: "I certify the Pa an tion laws of California." The applicant st call for all re ired ins ctions. Complete drawing on rem fSBl side. Date: Title: Signed _ ' FOR DEPARTMENT USE ONLY +� Date � Area Application Accepted by3 Date Data Final Inspection by v Pit or Grout Inspection by a a. F Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 r ❑ Stk 466-6781 ❑ Lodi 369-3621 Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. RECEIVED BY DATE PERMIT'NO.r FEE AMOUNT DUE AMOUNT REMITTED CA INFO :- �F b �S �A - � lG 7 [a o ♦.EH 13-24(REV.I/w 5) _ EH 14-2e