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APPLICATION FOR PERMIT • <br /> SAN JO D <br /> S (C <br /> AOUIN LOCAL HEALTH . <br /> IOA�OM - URLICHEAL�ggR AZELTON AVE., STOCK OINTCAT U <br /> one <br /> TAt NEALT�1 �MYEAR <br /> 866.6781 f 4raIf I) <br /> SPECIAL PE � TPIRES 1 YE v <br /> �`+�liy (CDm AR FROM DATE ISSUED <br /> made <br /> is hereby made to the San Jo"urn Plete in FEB 0 1 1990 <br /> made in compliance with S q Local TripllCate) <br /> Local H a^Joaquin Coun Health District for a <br /> Health District. N Ordinance No. 599 f Permit to construct an "NVIROP4MENTAI r' <br /> or sewage or No. 1962 for d/or install the work hlsipwU - HEAI <br /> well/pumP and the Rules and Regascrib s ofThis <br /> the application is <br /> Job Address 1444 Lincoln Wa <br /> Y San Joaquin <br /> Texaco Refining and City Stockton <br /> Owner's Name Marketing, Inc 10 Universal C t Lot sire 100'-250 r <br /> Groundwater Address Uni r a ity P Plaza �-- PM <br /> Contractor Technolocar InC* Ad 1401 Halyard Dr. 140 Phone (81 247 <br /> Address West Sacr ' Suite 8)5__.�._p5 `6 <br /> TYPE OFA WE—LUpIMAP,. NEI,6 WELL L7T nt0 (;a, <br /> License No. 434343 <br /> PUMP INSTALLATION Cl WELL REPLACEMENT ElR Phone 916 372_47 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR Ll DESTRUCTION 0 <br /> SEWER LINES OTHER 0 fiJU / <br /> FOUNDAMNAGRICULTURE WELLDISPOSAL FLD. <br /> OTHER WELL PROP' LINE _ <br /> INTENDED USE TYPE OF WELL PROBLEM PITS/SUMPS _ <br /> 0 Industrial pen ❑ Maoteoa A CONSTRUCTION SPECIFICATIONS <br /> 0 0 Bottom <br /> ❑ Domestic Private Ix Grand Pack Dia. of Well Excavation <br /> ❑Tracy Type of Casing PVC — Dia. of Well Casing 4" <br /> I'1 Public ❑ Other n Della r Specifications <br /> Depth of Grout Seal 25 <br /> I I Irrigation 4TApproz. Depth I I Eastern -- Type of Grout Neat Cement <br /> Surface Seal Installed by contractor <br /> Repair Work Done ❑ Type of Pump H P Well Destruction n Wel Diameter 10.5rr State Work Done _ - <br /> r Sealing Material (top 50'1 Bentonite and Neat Cement <br /> x-monitoring well � 95 Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I­­lREP) I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> installation will serve: Residence— Canmercial_ Other available within 200 feet.) <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a detach of 3 feet: <br /> SEPTIC TANK ElType/Mfg Water table depth <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. Ll <br /> Distales to nearest: Well Foundation Method of Disposal <br /> Property Line <br /> LEACHING LINE ❑ No.I Length of lines Total length/size <br /> FILTER RED ❑ Distnce to nearest Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS LI Disartce to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's sgnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in stich manna as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify list in the pedermance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California" <br /> The applicant ust for all repuir d insPlIctions Complete drawing on reverse si e.11�— <br /> Signed x Title:\7�4"-0-s-il Af t--S:5 � T_Date: -- <br /> /'/_7 �F no D MENT USE ONLY <br /> Application Accepted by �!L Date Area <br /> Pit of Grout Inspection by Date /j Final Inspection by Date <br /> Additional Comments: LI/n/Aer /OS 444 (fO " crct\_cAtwJtrrl <br /> Slk gFiO6181 WA 369-3621 0 Manteca 823-7104 0 Tracy 635-6395 1'- . <br /> A��`1r��1,�� pm COpIBS IO'.EnvitonmantBl"Oatth pa"IfalServices 1601 E. Hazelton Ave., P.O. Box 2009, stk., CA 95201 <br /> s� BY DATE PERM"NO- <br /> CK RECEIVED <br /> �J�N'F <br /> AMOUDUE AMOUNT REMITTED CA5N /JU.O J �.co I <br />