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APPLICATION FOR PERMIT r � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA M ' Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 Couun�Ordin�an�c/e No.54�age or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i u Job Address SE Corner Yosemite Ave. Fishback� City Manteca Lot Size 340' x 450 PM Owner's Name State Farm Insurance Address C/o Castillo Co. P.O. Box 21087Phone (602). 2.31-"9000 5729-F Sonoma Drive Phoenix, AZ 55036 1l Contractor BSK & Associates Address Pleasanton, CA 94566 License No. 490942 Phone 415 462-40DO TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I Geotechni.0 11 DISTANCE TO NEAREST: SEPTIC TANK —" SEWER LINES > 100' DISPOSAL FLO. PROP. LINE 80 r FOUNDATION 20 _ AGRICULTURE WELL., —_ ', OTHEfl WELL -- PITS/SUMPS — „ INTENDED USE f 'TYPE OF WELL PROBLEM AREA CONSTRUCTION`SPECIFICATIONS l' ❑ Industrial ❑ Open Bottom ❑ Manteca ' VIJia. of Well:E 2cavation Dia. of Well Casing ' � Hollow Stem L7 Domestic/Private ❑..Gravel Pack ❑ Tracy `� Type of Casing Specifications FI Public i Other; JCI Delta ~� Depth of Grout Seal'� 20i' Type of Grout Sack +: - I I Irrigation 2.0'Approx. Depth' .I I Eastern Surface Seal Installed by N ' Cement Repair Work Done ❑ ' Type of Pump. - " H.P, '•State Work Done_ 1 Well Destruction ❑ Well Diameter c Sealing Material f=iller Material (Belowr-50,)- , TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is # * available within 200 feet.? Installation will serve: Residence{_. Commercial s Other z N/A Number of living units:, Number of bedrooms j - Pi . • �. � Character of soil to a depth of feet: ' ` f Water-table depth SEPTIC TANK r❑ YType/,Mfg Capacity k-No. Compartments f PKG. TREATMENT PLT.`❑, s Method of Disposal Distance to nearest: Well Foundation Property Line I 7 3 t jl LEACHING LINE '❑ No. & Length,of lines Total length/size NSA FILTER BED f❑'`Distarice to nearest:_ Well Foundation Property Line SEEPAGE PITS I I .Depth t Size € Number t N/A SUMPS ❑ Distance to nearest: Well,. !Foundation Property Line DISPOSAL PONDS }❑s4» t +e I hereby certify that I have prepared,this application and that the work will be done in accordance with San Joaquin county ordinances, st4awsanrules and regulations of the San Joaquin Local Health Di%trict.Home owner or licensed`agent's signature certifies the-foliowing:"f ce�ify that in the performance of the work for which this permit is issu , 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 taws of California." The applican/t% iiuy calI requirELd=�9�Title�lanager, awing on reverse side. `+, �^ /" �- � Geotechnical1.Service�ate: 04/06/90 Signed X - ..., _ ,.,-- —Alex. Y. Eskandari� T f FO DEPARTMENT USE ONLY Application Accepted by d Dace Area f ' Pit or Grout Inspection by Date . Final Inspection b Datf� Additional Comments: - ❑ Stk 466-6781 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 11 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE "AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. INFO r.EH 13-241REV.I/]15) }/3fq v �GGt r1 EH 14-28 / iS Ca IO �I •