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t V, N APPLICATION FOR PERMIT" JOAQUIN LOCAL HEALTH DISTRICT pAYM�yED 1601 E. HAZEL T ON AVE., STOCKTON, CA RECE �. �► Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC (Complete in Triplicate) NMENTAL HEALTHEn de Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein destp4fn is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regul s o file San Joaquin Local Health District. Job Address 110 West Sonora Street City Stockton Lot Size 300'X720' pM Owner's Name City of Stocktonjublic W9& City Ha11,Stockton Phone (209) 944-828 Contractor, Spectrum Exploration Address 2825 E. Myrtle Street License N0512268 Phone (209)-465— 71.2 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ I ! 1 PUMP INSTALLATION EI SYSTEM REPAIR ❑ OTHER PrnWT: WGIL, DISTANCE TO NEAREST: SEPTIC,TANK >I 00' SEWER LINES 100' DISPOSAL FLD.2Q� PROP. LINE __3_0_' FOUNDATION 90_1_._- AGRICULTURE WELL>2nnn" OTHER WELL 1375' PITS/SUMPS ->2-00' k p , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing 2'" 11) ❑ Domestic/Private KI Gravel Pack ❑ Tracy Type of Casing Specifications Schd 40 171 Public ❑ Other ❑ Delta Depth of Grout Seal 20' Type of Grout Neat Cameat. I I Irrigation -Approx. Depth i I Eastern Surface Seal Installed by We.I 1 r1ri I ling_Cnntrartar _-_ Repair Work Done ❑ Type of Pump H.P. State Work Done 0 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION 1"] REPAIRlADDITION { I DESTRUCTION [ I (Noavailable septic system permitted if public sewer is available within 200 feet.), C Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 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 ❑ No. & Length of lines Total length/size FILTER BED `❑' Distance to nearest: - Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 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 Di§trict. 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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." SA•N )OAQU1N LOCAL HEALTH DISTRICT The:pplica mu t c ll for all required inspections. Complete drawing on reverse side. ENVIRONMENTAL HEALTH DIVISION Signd X ,_.__ Title: tePEg9ff/R fi FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data 0-14'AW' Final Inspection by Date 4 Additional Comments: [1) Stk 466-6781 C3 Lodi 369-3621 ❑ Manteca, 823-7104 ❑ Tracy 835 6385 Applicant - Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24{REV. EH 14.26 t