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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZELTON AVE STOCKTON, CA it Telephone (209) 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Trlpl-cate) ' 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 welltpump and the Rules and Regulations of the San Joaqum Local Health District i� Jab Address 500 West Hospital Road City Stockton Lot Size PM Owners Name San Joaquin County Address County House , Room 678 Ph,,,(-209)468-21810 Spectrum 2825 East Myrtle Contractor Exploration Address Stockton , CA License No 512268_.___-Phone (209)465-E712 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION %I {� PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 A ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' [ I Public ❑ Other {-1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx Depth i I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H P State Work Done Well Destruction (K Well Diameter 2—Inch Sealing Material (top 50) RA n t o n T t e—Per I -T.I t t a (3 wells) Depth 50 feet Filler Material (Below 50) Not applicable TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet I 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 Ll No & Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS Cl 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 Contractors 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 ahfomia ' The apphca t must call for II required inspects ete drawing on reverse side �+ Signed X ° G Title Project Geologist pate 3 S ! 3 ' FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by Date ditronal Comments Stk 466 6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 0 Tracy 835 6385 Applicant Return all copies to Environmental Health Permit/Services 1601 E Hazelton Ave P O Box 2009 Stk CA 95201 fFE INFO AMOUNT DUE AMOUNT REMIT-FED C K RECEIVED BY DATE PERMIT NO 1 3 2{(REV i i r 5i �14 26