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APPLICATION FOR PERMIT PA V SAN JOAQUIN LOCAL HEALTH DISTRICT; 'r "A a 1601 E. HAZEL T ON AVE., STOCKTON, CA s�p Telephone (209) 466-6781 fU BANJO PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDeNV/UQ4IO AQ{� (Complete in Triplicate) �pNME hrrry 'f ... Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describe iY.'16ts 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 S<irZ}ioaquin Local Health District. .Hospital Lane City French Camp Lot Size PM Job Address DeeA o Q:4ali P . -OwnersName Sall Joaquin County __ Address Count House R Phone .o9 Contractor Spectrum Drilling Address2825 E. Myrtle Street License No. 512268 Phone 465-8712 TYPE OF WELL/PUMP: NEW WELL C6 WELL REPLACEMENT ❑ DESTRUCTION ❑ S0,1 Boy i;,r a-I—$•t T PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERXJ Exploratory Borin s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD FI5O PROP. LINE FOUNDATION -3-6' AGRICULTURE WELL t 150 OTHER WELL+150 PITS/SUMPS-U50 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Neat Cement I'1 Public I Other 1-1 Delta Depth of Grout SealDepth of BoringType of Grout Bentonite .-_ I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by Slurry Repair Work Done 11 Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 50') Neat Cement/Bentonite Slurry Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION t I (No septic sys ermined it public sewer is avail bl in 200 feet. Installation will s rve: Residence_ Commercial_ Other Number of living units. Number of bedrooms Character of soil to a depth of t: 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 Ll No. & Le�to �rest: Ii Total length/size FILTER BED (-I DistanceWell Foundation erty Line SEEPAGE PITS i I De Size _ Number SUMPS LI rstance to nearest: Well Foundation Property Line 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 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 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." The applican it call f I squire i pections. Complete drawing on reverse side. Signed x Title: Senio eolo i t Date: _9/10/93 ill el?, (� �. FOR DEPARTMENT USE ONLY Application Accepted by Date — -9 Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-ti385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 D FEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT'NO. I INFO CASH LT- EH - .EH 13-241REV.rixsl vT EH 1426 /