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%gsr APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICT CGTY 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby 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 500 West Hospital Road city Stockton Lot Size PM Owner's Name San Joaquin County Address County House; Room 678 Phone 209)468-218 Spectrum 2825 East Myrtle Contractor Exploration Address Stockton , CA License No. 5122FiR Phone (209)465— 712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION xl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public n Other n Delta Depth of Grout Seal Type of Grout_ 1 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction (X Well Diameter 2—inch Sealing Material (top 50') BPntoni to—Ppr T.- Tvrkpttp (3 wells) Depth 50 feet Filler Material (Below 501 Not applicable TYPE F SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation w me: Residence_ Commercial_ Other Number of living um Number of bedrooms Character of soil to a depth 3 feet: Water a depth SEPTIC TANK ❑ Type . Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near Foundation Property Line PAY LEACHING LINE ❑ nTh of Ii s Total length/size— FILTER ength/size FILTER BED Distance to ne st: Well Founds' n Property Line A UIN COUNTY SEEPA ITS I Depth Size Number CC ``1111ppBLIC H TH DIVISION SU S Ll Distance ti nearest: Well oundation Propertpll�RM`ON MENIAL 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 Di3trict. Home owner or licensed agent's signature certifies the following: "1 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 folio . " 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 alifornia." The applica t must call for II required insp cti to drawing on reverse side. SignedX �'• Title: Project Geologist Date: 3 8 3 , �� /j P oIn F R DEPARTMENT USE ONLY Lit ms`s Application Accepted by ai117`rA1A IAN l( Wl� Date ��1�^J Area Pit or Grout Inspection by /�„ /Date //,Final Inspection by en iVda ""'"^ Date Additional Comments: 4� �?(- �' _t%X/ir� IIf_fro (9GC- 70 ❑ Stk 466-6781 ❑ Lodi 3694621 ❑ Manteca 823-7100 4 ❑ Tracy 835-6385 ('''� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 S 1 INFO FEE AMOUNT DUE AMOUNT REMITTED / CCK If_ RECEIVED BY OAT PERMIT'NO. . EHtaa,1REV.1/Rel WO I/I EH 1C2a TTT ��YYY tt1 ��YIIV///