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lSj\t\o APPLICATION FOR PERMIT � �q 6�t) LKpt��oN :fie,. SINXIN DAWN JOAQUIN LOCAL HEALTH DISTRICT VAN LdP� 1601 E. HAZE T ON AVE., STOCKTON, CA F PN�O ONMEN r��Q� Telephone (209) 466-6781 5 �NvIR �Je�G PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `' {- (Complete in Triplicate) Application is hereby made to the San Jbaquin 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. 102 S_ Wilsoll�Wa Stockton Job Address Y City Lot Size PM E Owners Name Rock Brothers Address 3736 S. Highway 99, Stockton phone 209-464-8344 �I Contractor Bay Area Exploration Address P-fl- Box 157, Suisun CA License No, C57-522125 Phone 707-864—213 - TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT © DESTRUCTION ❑ groundwater PUMP INSTALLATION ❑ SYSTEMREPAIR El OTHER f� monitoring wells O DISTANCE TO NEAREST: SEPTIC T,�ANK SEWER LINES DISPOSAL FLD. PROP. LINE c. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ 8w____ Dia. of Well Casing 27 ❑ Domestic/Private Lit Gravel Pack ❑ Tracy Type of Casing PVC Specifications f"1 Public ❑ Other r n Delta Depth of Grout Seal .-_- 35Type of Grout Cement _ I I litigation --Approx. Depth L I Eastern Surface Seal Installed by Bay Area Exploration Y Repair Work Done ❑ Type of Pump N/A H.P. N/A State Work Done Well Destruction ❑ Well Diameter 2n Sealing Material Itop 50'1 Cement/Bentonite/Sand Depth 055, Filler Material {Below 501 Sand n �a TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is _.I available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: '.Number of bedrooms Character of soil to a depth of 3 feet 1i. Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i J Method of Disposal f I Distance to nearest: Well Foundation Property Line , LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line `I SEEPAGE PITS I I Depth + Size Number 'FV SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ v 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 District. Home owner or licensed agent's signatu',re certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to.become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work fol which this permit is is&Abj Ifle�lR[ 10#CogIeAEuptMLcllWr� geypensaV tion laws of California." t ENVIRONMENTAL HEALTH DIVISION The applicant must call f re red ins ion fete drawing on reverse side. SPECIAL PERMIT 1 Signed X Title: Manager - Date: 10/25/88 John lis FOR DEPARTMENT USE ONLY Application Accepted by Date X49 Area Pit or Grout Inspection by Date/ 5� Final Inspection by Date ci 99 Additional Comments: . I4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED SASH nnRE`C/EEIVED BY � DATE y PERM! N0. ♦.EH13-24(REV.1/"Sl S # 51y t/I+i p� �h �-��Q� �� EH 14-2e