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" PUBLIC HEALTH SERVICES SAH JOAQUIN COUNTY P.O. Box 2009 (1601 East Hazelton Avenue) Stockton, California 95201 PERMIT EXPIRES 1-YEAR FROM .DATE ISSUED (Complete in Triplicate) 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 f'��1 e ulations of the San Joaquin Local Health District. �� NOR L Job Address 102 South. 1ti�1'�"SOn_'Itidy MU PM ft/4 j!�y�Owner's Name Jay Roek/RoekkrotherS AddressP•0. Box 30038 StoCkton,CA 95213phone4-$344 Contractor PC Exploration Address 1780 Vernon St. , Ste E License N0.265556 Phone916/783-9733 _ I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION.❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XX Soil BO 7 n S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PA t0 11l eet FOUNDATION AGRICULTURE WELL OTHER WELL 9�9tfM?* INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation b'inG Dia. of Well Casing None ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing None _ee Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal — Type of Grout Cement f I Irrigation— i —,-Approx. Depth I I Eastern Surface Seal Installed by - �Repair Work Done ❑ Type of Pump1 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_! Commercial_ Other I 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mf I 9., Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No- & Length of lines Total length/size -rs FILTER BED ❑ Distance to nearest: Well Foundation Property Line j I w SEEPAGE PITS I I Depth I Size Number I SUMPS' II Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have,prepared this appliSoion 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 signature.certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ p y an y 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: "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." The applicant st I f all required inspections. Complete drawing on reverse side. Signed X Title: Y�61q e Date: - 7// FO AR NT USE ONLY �� Application Accepted by Date Ar Pit o Grout Inspection by Date �' G� j Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621' ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmehtal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK ]NFO AMOUNT DUE }� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. a EH - 1424{HEV.i i H 5t EH a-2e I