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ppYMEKT rr �.I APPLICATION FOR PERMIT RE CEti V ED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA p,�R l�" Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEAL��1 (Complete in Triplicate) pERM1YISERVI— 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 r 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 444 South Wil9on Way City Stockton Lot Size PM San Joaquin County 222 East Weber 'k= owner's NameGeneral Services Address Stockton, CA 95202 Phone944-3675 Spectrum 2825 East Myrtle Avenue Contractor_Exploration, Inc. - Address Stockton, CA 95202 License No.C-57512268 Phone L209) 465-87 12 TYPE OF WELL/PUMP:. n -k. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER tR Soil Borrings (6) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca r Dia. of Well Excavation Dia. of Well Casing �i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ls Type of Casing Specifications FI public IOther 1 17 Delta x Depth of Grout Seal Type of Grout I I Irrigation _..Aper x. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ElWell Diameter Sealing Material {top 501 backfill sand/cement slurry 20 ft. to Depth FiIIe�Material {Below 50') Surface 11 TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR'/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is i, available within 200 feet.) Installation will'serve: Residence_ Commercial_ Other LA Number of living units: E Number of bedrooms !L' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r; PKG. TREATMENT PLT. L) Method of Disposal l 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- SEEPAGE ine-SEEPAGE PITS I ] Depth ! Size Number '^ SUMPS ❑ Distanceo nearest: Well Foundation Property Line -^ = DISPOSAL PONDS ❑ }-� - I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and t ' ' rules and regulations of the San Joaquin Local Health Diltrict. € Home owner or licensed agent's signature'certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not ! employ any person in such manner as t&become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." ` The applicantst call for all requir`CHns ctio Complete drawing on reverse side. k. = Signed X Title: Date: 7 ' R D P7ENT U5E ONLY - JT Application Accepted by Date Pit or Grout Inspection by '� Date Final Inspection b Date Additional Comments: ' - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M5 (i Applicant - Return all copies to: Enviro"nmental Health Permit/Services1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ei FEE AMOUNT DUES AMOUNT REMITTEDR RECEIVED BY DATE PERMIT'NO. INFO a,EH14-281REV.iin51 % ' - t'