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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA +�µ�, 2 f Telephone (209) 466-6781 `' 1987 PERMIT EXPIRES I'YEAR FROM DATE ISSUED ENVIROMiENTAL HEALTH (Complete in Triplicate) FEWIT/SERVICES 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 12 5O NORTr-r W I I SON WAY City Lot Size PM Owner's Name THRIFTY OTI COIAp 213 923-9876 qyy. Address tnnnn r erct=wenn rtr un m>Ju�y�e g�24�.Phone_ _ SPECTRUM EXPLORATION, INC. 2825 E. MYRTLE ST. STOCKTON ti 532268 209.498-2720— Contractor Address -license-No, Phone - h TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERT®FOUR-20-TFOOT.:SOIL DISTANCE TO NEAREST: SEPTIC TANK N/n SEWER LINES n/a DISPOSAL FLD. n/a PROP. LINE rt30RINGSn FOUNDATION AGRICULTURE WELL nfa OTHER WELL n/a PITS/SUMPS da INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0Inc es Dia. of Well Casing n/a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing /a Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal zero to 20Type of Grout r.pR6rateLl p.tqr ite I I Irrigation —.Approx..Depth 11 Eastern Surface Seal Installed by drilling contractor 1 - Repair Work Done L3 Type of Pump n/a H.p. n/a State Work Done_ n/a Well Destruction 0 BRmetera Sealing Material (top 50') n/a Depth 20 feet Filler Material l8elow 501 n/a TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is L available within 200 feet.) InstallaW n will serve: Residence! Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:1 Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tonearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS N/A L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ li 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 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-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 oil re�ersa side: _ lJLLYMGa %/w•tpi..r{��.. . "° i -- Signed X � - —Title: -PROJECT GEOLOGIST-- -- Yr- Date: 12-18-87 /l FOR DEPARTMENT USE ONLY Application Accepted by Date 7/�7ii�`i��} Area Pit or Grout inspection by � t Date Final Inspection b Date Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, ca FEED I INFO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT..NO. ik + EH 13-24rREV.1 sr EH 14-M OO - t to FELL137-H I