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TECHNICAL_WORK-9LAN. APPROVED BY THE REGIONAL TER-QUALITY CONTROL BOARD, CENTRAL VALLEY REGION. APPLICATION FOR PERMIT Contact. �' ► s•�r .4. SAN JOAQUIN LOCAL HEALTH DISTRICT GARY REENTS, (Project Engineer : 2 1601 E. HAZETON AVE-, STOCKTON, CA (916) 361-5742 0 Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE.ISSUED ` (Complete in Triplicate) Q � / #. 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_. . , .Poi m Avenue ' # Job Address City Lot Size PM Owner's Name Southwest Hide ComPdnyAddress P.O. Box 2083,--Manteca,- CA 95je (209) 599-4251 _ I C-57 Address ress Li Contractor eccense No. Phone Spectrum Exploration 2825 E. Myrtle Street 51226$ 465-8712 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION © Miat. E50F41Jro. I PUMP INSTALLATION 0 SYSTEM REPAIR ElOTHER I Monitoring Wel I 8 s DISTANCE.TO NEAREST: SEPTIC TANK 1001 SEWER LINES 100 r DISPOSAL FLD. r PROP. LINE 20 FOUNDATION 10 AGRICULTURE WELL 100 OTHER WELL 50 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial Open Bottom A Manteca Dia. of Well Excavation 21r Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications11�J F] Public 170 Other ❑ Delta Depth of Grout Seal +41 Type of Grout iP 1.1 Irrigation " -Approx. Depth ! I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 ` Depth - Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 HLPAIR/ADDITION ! I DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) " Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms x Character of soil to a depth of 3"feet: Water table depth SEPTIC TANK Type/Mfg.- Capacity-_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal " Distance to nearest: Well Foundation Property.Line LEACHING LINE Cl No. & Length of lines Total length/size R FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number i SUMPS Ll Distancer'to nearest: Well Foundation Property Line ; DISPOSAL PONDS 0 (,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, I shall not I .� 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." f" +r The'applica t call for all re=edtn ions. Complete drawing on reverse side. ,Z a Signed X Title: / Date: v f FOR DEPARTMENT USE ONLY Application Accepted by /L, Date Pit or Grout Inspection by, Dater'::_ Final Inspection bv. Date= �� Additional Comments: ❑ Stk 466-6781 EI 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, Stk., CA 95201 rCEINFO i AMOUNT DUE T AMOUNT REMITTED CSM REC IVED BY [)ATE PERMIT NO. i ' ♦.EH 13-24{REV.t i N ar EH 14-2a �r S+'". n •g'(]J� O!/ �=Cid lam/ .