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a' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" 4 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED {Complete in Triplicate) Application is herehy 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 C, only Ordinance No.549 for sewage or No, 1862 for welllpurnp and the Rules and Requlations of the San Joaquin Local Health District. Job Address _12 0 NORTu WTI SnN WAY _ CitySTOCKTL1N Lot Size PM Owner's Name THRIFTY OII COMP_.I Address CA-90244)--f- Phone 213 923-9875 -;DOW-LAKEW000-8411a�BQWAIE�,- Contractor SPECTRUM EXPLORATION, INC 2825 2825 E. MYRTLE ST. STOCKTON License No. 512268 Phone 209 498-2720 ! TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT i_1 DESTRUCTION 0 I PUMP INSTALLATION Ll SYSTEM REPAIR [J OTHER 09 FOUR 20 FOOT SOIL DISTANCE TO NEAREST: SEPTIC TANK _ N/a SEWER LINES - n/a DISPOSAL FLD._ _/a PROP. LINE BORINGS j FOUNDATION AGRICULTURE WELL P_Ld.....__— OTHER WELL__DZ0__ PITS/SUMPS _n1_a INTENDED USE TYPE OF!WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i I Industrial {J Open Bottom 1J Manteca Dia, of Well Excavation 15 inc es Dia. of Well Casing n/a f I i Domestic/Private J Gravel Pack 1 1 Tracy Type of Casing n/a Specifications i 1 Publrc I Other I I'I Delta Depth of Grout Seal _LQ_LL_20' Type of Grout_concrat4a/bento ` I I Irrrrlanun T Approf Depth I I Eastern Surface Sudl Installed by drilling contractor f Repair Work Done Ll Type of Pump _n/a H.P. n/a State Work Done — n/a I / Well Destruction ] '69meter _S i;: Sealing Material (top 50'1 n a Depth 20 Meet Filler Material (Below 50'1 n/a F TYPE OF SFPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if public sewer is ,m / available within 200 feet.) Installation will serve: Residence Commercial _ Other i Number of living units: Number of bedrooms Character of soil to a depth o1 3 feet: Water table depth SEPTIC TANK IJ Type/Mfg Capacity. No. Compartments PKG- TREATMENT PLT, 1.1 Method of Disposal Distance/I:to nearest: Well Foundation Property Line LEACHING LINE l No. 8 L,r,glh of lines Total length/size FILTER BED 11 Dislance to nearest: Well Foundation Property Line _ N/A SEEPAGE PITS 11 Depth I Sire _ _ _ Number SUMPS N/A 11 Distance to nearest. Well .. Foundation Property Line DISPOSAL PONDS 11 ' 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 4 rules and rellulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall not ernploy 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: "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 must call for all required inspections. Complete drawing on reverse side. —S� �' ( l rxr[/ d/ur,0",_A Signed 7(_ / Title: PROJECT GEOLOGIST Date: 12-IR-87 } FOR DEPARTMENT USE ONLY i � 7 I i Application Accepted by b" ^-rte— - Date y�� 7 tea t Pit or Grout Inspection by Dal—_/h U 7,Final Inspection by C Date i Additional Comments: ❑ Stk 4666781 (71 Lodi 369-31521 ❑ Manteca a23-7104 ❑ Tracy 835-fa365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i f1tv FEE AMOUNT DUE AMOUNT REMITTED RECHVED BY DATE PERMIT'NO. INFO CASH