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APPLICATION FOR PERMIT 41 PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP 19 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) VIRONMENTAL HEALTH PERMIT�SERV.6C� 51 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here) escrl his 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 Heaver District. SAP(. JOAQUIN LOCAL HEALTH DISTP.ICI ENVI[�gTAkLTH p)u010N Job Address 102 South Wilson Way city Stockton Owners Name Don Roek/Roek Bros. Address P.O. Box 30038 Stockton 95213 Phona209/464-8344 Contractor PC Exploration Address 1780 Vernon St.. Ste.E License No.265556 ' Phone 916/783-973 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ NOn1torinct WeLL PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER W (2) Vic-• .L�•••` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES >SO r DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation inches Dia. of Well Casing `l art ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SchedULe 40 PVC Specifications I1 Public XI Other 2 Ws Fl Delta Depth of Grout Seal -570' Type of Grout cement ._ 1 I Irrigation Ln 11 Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Tly]pe of Pump NA H.P. NA State Work Done_ Well Destruction ❑ Well Diameter NA Sealing Material Itop 50.1 C2ExPx H d� 0 I' Depth Filler Material (Below 50'1 sand gravel pack �1 TYPE OF SEPTIC WORK: NEW INSTALLATION L 1 REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) ! ,, Installation will serve: Residence_ Commercial_ Other t/ 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. Corqpartments PKG. TREATMENT PLT.❑ Method of,Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size (� FILTER BED ❑ Distance to nearest: Well Foundation Property Line Z SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 laws, and rules and regulations of the San Joaquin Local Health Dr3trict. 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 nor employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subjnct to workman's compansa tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Titlot�t8m L,41 Date t iw; .. FOR ERT SE ONLY �. Application Accepted by —� F `• / Date .�Area Pit or Grout Inspection by D. Final Inspection by�� te/ "gin / Additional Comments: ❑ Stk 466.6781 ❑ Lodi 3693621 ❑ Manteca 8237104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazolton Ave., P.O. Box 2009, Stk., CA 95201 INF EO AMOUNT DUE:1 1 AMOUNT REMITTED CK t RECEIVED 6Y DATE PERM17'NO. . EN1324 IREV.Ir x ar _5 3$ 3srco /�-/��`I `ff-ZSgj EN N82