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APPLICATION FOR PERMIT * PAYMENT LT{►U15 1 �JOAQUIN LOCAL HEALTH DISTRICT RECEIVED UIN IACAL H pIV15TON AVE., HAZEL t V Lo niGIALA�°HpE,T,ml, 1601 E. Telephone 20914666S1TON, CA SEF' 191939 sp�E' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) VIRONMENTAC HEACTI� PERMIT jS�RVLq§Sr 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 102 South Wi Lson Way City Stockton Lot Size PM Owners Name Don Roek/Roek Bros. Address P.O. Box 30038 Stockton 95213 Phone209/464-8344 Contractor PC Exploration Address 1780 Vernon St.i Ste-.E License Ne.265556 ' Phone 916/783-973 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Monitoring WeLL PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER W (2) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES >50 DISPOSAL FLD. PROP. LINE 1 I 0 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation inches Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSchedu Le 40 PVC Specifications ('1 Public A Other 2 Ws S n Delta Depth of Grout Seal 50 ' Type of Grout cement -_ I I litigation r Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump NA H.P. NA State Work Done _ Well Destruction ❑ Well Diameter NA Sealing Material (top 501 C I me""'F drn U {" Depth Filler Material IBelow 50'1 and Cravel. pack _ TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION I I DES CTION ` INo septic systerrl permitted if public sewer is J/7 table within 200 feet.)Installation will serve: Residence_ Commercial_ Other r Number of living units: _ Number of bedrooms �/ Character of soil to a depth of 3 feet: table depth_ SEPTIC TANK ❑ Type/Mfg Capacity ompartments PKG. TREATMENT PLL❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D 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 n 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 D13trict. 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 of sub-contracting signature eanifies 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 must mmuuustt call for all required inspections. Complete drawing on reverse side. . Mot lf;,�� Titla`_ .I 1M Dato ur f FOR fPART SE ONLY Application Accepted by >��—�� Date /�' /~ � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 36.9-3621 ❑ Manteca 823.7104 ❑ Tracy 635-6M5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazolton Ave., P.O. Boa 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CCASl1 K RECEIVED BY DATE PERMIT-NO. • iN 13-24 IREV.11 x!1 EH NRa