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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hei.eby 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 540 West Scotts Ave, CityStockton LotSize280 'x300 ' PM 147 ,p 04 Owner's Name Sheridan Randolph Address P.O. Box 23731, Oakland, CA$hon4415) 444-8790 94623 Conlractoppectrum Exploratignress2825 E. M rtle,StocktRP15eNo 512268 —Phone(209) 465-8 12 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER]6�X soil borings DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 5 5 r FOUNDATION 30AGRICULTURE WELL OTHER WELL 30 ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_.8" Dia. of Well Casing na Ci Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing---Ila_ Specifications F] Public (71 Other Cl Delta Depth of Grout Seal 0-8 ' r 10 ' _ Type of Groutbe ±-o f_ra- I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by frP_P_ fa 1,1 CPrnent _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50')btOriite—CE?1TteIIt _ Depth .8 ' , 10 ' Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within'200 feet.) yr Installation will serve: Residence_ Commercial— Other X Number of living units: Number of bedrooms O Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. C6mpartments PKG. TREATMENT PLT. ❑ Method of Dispo Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line,017 �4,N SEEPAGE PITS i I Depth Size Number N \� SUMPS Ll Distance to nearest: Well Foundation Property Line^�CII C3 DISPOSAL PONDS ❑ 1 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 Di%trict. Home owner or licensed agent's signature certifies the following: "["certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 Cali ia." The applica m t call for all qui r ctions. Complete drawing on reverse side. Signed X Title: Date: } FOR DEPARTMENT USE ONLY Application Accepted by DateU ( Ar 3D Pit or Grout Inspection by Date Final Inspection 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED 8Y DATE PERMIT'NO. EH 13-28 V I`'-T/��`