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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 ,gECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSU (Complete in Triplicate) AR 0 7 1990 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/JPNMEPNTA�L t This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pl Jl�li� f the San Joaquin Local Health District. AL H DIVISION Job Address SE Colder March lane and West line City S 6On Lot Size PM Owner's Name Uttocal Corporation Address 2175 North California Blvd. Phone 415-945-7676 Contractor�S=tnwn Drilling Address 2825 Fast Myrtle St. License No. 467252 Phone 209--465-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER cm Soil Borings/no well inst DISTANCE TO NEAREST: SEPTIC TANK r1M SEWER LINES ate DISPOSAL FLD. Ttote PROP. LINE (gas) 150ft FOUNDATION DOW AGRICULTURE WELL rKM OTHER WELL 150 ft PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation 8 inch Dia. of Well Casing NA ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of�qgg NA Specifications ('I Public ❑ Other F1 Delta Depth of Grout Seal 50 ft Type of Grout berttonite I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by Spectnm Drilling Repair Work Done U Type of Pump/ H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I IIEPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CaParitv No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundaft Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS I I Depth Size _ _ _ Number SUMPS LI Distance 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 Di?;trict. 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 applicant mus I for all eq ed inspections. Complete drawing on reverse side. Signed X_ _ Title: Project Geologist Date: 2/28/90 F R PA NT USE ONLY �j Application Accepted by Date O Area ✓ J Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ;ERIT NO. + EH 14.26(REV.iiNsl 35� �(�(� ^ ^��10 �/7 EH 1t-2D J I