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1, r APPLICATION FOR PERMIT ' SAN JOAQUIN LOCALHEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �`T 1 :1 ;V,j Telephone (209) 466-6781 E ISSUED R FROM DAT + PERMIT EXPIRES 1�YEA, ✓N20^.ji,:;:N-Ii1Iu^` (Complete in Triplicate) L.r11l'o nOid - ridlo her Application is he,eby made to the San Joaquin Local Health District for a permit to construct a111pu install the work and R gelation This application is made in compliance with San Joaquin County Ordinance Na.649 for sewage or No.1862 for we pump and the Rules andRegulationsof the San Joaquin Local Health District. 'o n,'P.,'. PM City c ktotl_..—,Lot Size Job Address e D 209 466-5251 ProduCis 800 West Church St. Stockton ton Phone Gold Bond Building Address 6 Owner's Name Rancho Cordova 51942B Phone B6F Drilling Inc_Address 3663 OtBec Circle LicenseDESTRUCTION ❑ Contracts WELL REPLACEMENT ❑ OTHER dl 15 boreholes NEW WELL ❑ TYPE OF__ WELL/PIMP: SYSTEM REPAIR p PROP. LINE PUMP INSTALLATION ❑ SEWER LINES DISPOSAL LLD. ' DISTANCE TO NEAREST.: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS, �— FOUNDATION - ��y�•- CONSTRUCTION SPECIFICATIONS Dia-of Well Casing INTEN�ED USE TYPEOFF WELL PROBLEM AREA s p Open Bottom ❑ Manteca Dia.of Well Excavation_� Specifications ❑ Industrial ❑Tracy Type of Casing�-�' ❑ Gravel Pack Delta Type of Groutnent Lem ' ❑ Domestic!Private - ❑ DeDepth of Grout Seal __----- T _ n Public (X Other Surface Seal Installed by Q I I Inigaden 10 ft-14 ft-TApprox. Depth I I Eastern H.P. State Work Done TWO of Pump —�--- O Repair Work Done ❑ Sealing Material (top 509 Well Destruction ❑ Well Diameter Depth Filler Material (Below 50'1 available within 200 teen.( TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sower is Installation will serve: Residence_ Commercial— Other Number of living units: — Number Number of bedrooms Water table depth t 'Character of soil to a depth of 3 feet: Capacity . No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal # - PKG.TREATMENT PLT.❑ Foundatigh Property Line - Distance to nearest Well Total length/size LEACHING LINE Ll No. &Length of lines Foundation FILTER BED Property Line ❑ Distance to nearest: Wall Size Number SEEPAGE PITS 11 Depth Foundation Property Line SUMPS Ll Distance to nearest: Well _ DISPOSAL PONDS 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state I sshhall not rules and regulations of the San Joaquin Local Health Di§trict.g. nature Home owner or licensed agent's signature certifies the foaowin 'I certify that in the performance the Conk for which this permit o issued, f Homey any Person in ed 3 manner as to became subject to workman's compensation laws of California.,'rnContractor's hiring or so workman's signature certifies the following:"1 h ma neat m the performance of the wank for which this permit is issued,I shall employ persons subject to workmates compensa- tion laws of California." The applicant py+at call for Title:rH9yired ins cions. Complete drawing o^ reverse aide. �i �i"�^a7i Data: E�...� Signed -t.• FOR DEPARTMENT USE ONLY 3_----__ .. Date 'A0Aree .Appl'Icstion Accepted by i. Data '• n Date Final In by Pit or Grout Inspection by 4- ' Additional Comments: ❑ Manteca e23-voil ❑Tracy 835-M Stk., CA 85201 - r ❑ SO, 46fr6781 ❑ Lodi 3633621 Applicant- Return all copies to: Environmental Health Pennit/services 1601 E. Hazelton Ave.. P.O. Box 2008. • REMITTED cA RECEIVED By DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT INFO ` �/ IO� O O 4 •.EN la-2,(,W.vast .�, � 5-S -76v\ ER 1418