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#6PNo APPLICATION FOR PERMIT • O VooN\4 �11A 1601 E. HAZENLOCAL HEALTH T TONAVE., STOCKTON CA N NON 03 �P`�''? Telephone (209) 466-6781 $P�Nv1R Se�G PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t and/or install the rk Applicat I compliance writh SanoJoaquinthe SanCouJoanty Ordinauin Localnce No.549 for sewage or Health District for a permit No. 1862 forcwell//pump and the Rues and herein Regulations of he Sancation is Joaquin Local Health District. Job Address 102 S. Wilson Way City_Stockton Lot Sire PM -� Owner's Name Roek Brothers Address 3736 S Highway 99 Stockton Phone 209-464-8344 Contractor Bay Area SXplorationAddress P.O. Boa 157, Suisun CA License No.�22t25Phone?07-864-213 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl groundwater PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER CSF monitoring wells DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 401 DISPOSAL FLD. PROP. LINE AGRICULTURE FOUNDATION AGRICULTUflE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation---8f— Domestic/ 8fSpecifications , 0 Domestic/Private Gravel Pack ClType of Casing PVC Tracy Type of Grout Pn I Public n Other ❑ Delta Depth of Grout Seal ��' I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by BaX Area EXP1QratiQ1 Repair Work Done 0 Type of Pump N/A H.P. N/A State Work Done — 2' Sealing Material (top 50'1 Cement/Bentonite/Sand � Well Destruction ❑ Well Diameter 9 1.� Depth 55' Filler Material (Below 501 __SAnd -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I available within system umittud if public sewer is 1 Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK 0 Type/Mfg Capacity No. Compartments � Method of Disposal '. PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line i A LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size _ Number Property Line - SUMPS ❑ Distance to nearest: Well Foundation P Y 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, artd rules and regulations of the San Joaquin Local Health DiMrict. 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 ensa- certifies the following: "I certify that in the performance t the work for which this permit is isgAhJ 11MAQUI04 II-�AEuPWAL01"rN"Imp tion laws of California." ENVIRONMENTAL HEALTH DIVISION The applicant must call f I re red ins p ion plate drawing on reverse side. SPECIAL PERMIT — Title: Manager Date: 10/25/88 Signed John lis FOR DEPARTMENT USE ONLY Date Area Application Accepted by Pit or Grout Inspection by - Date Final Inspection by Additional Comrtwnts: ❑ Stk 466-6781 0 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 FEE CK RECEIVED BV DATE n�S_5z�_ INFO AMOUNT DUE AMOUNT REMITTED CASH ( /L I'�14� `�,� . iii �� 1 . EH 13-24 IREV.11 nsl y - EH I4-M