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r i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVC., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 500 west Hospital Road City Stockton Lot Size PM Owner's Name San Joaquin County Address County House ; Room 678 Phone 209 468-218 Spectrum 2825 East Myrtle Contractor_. E_ xI?lar�tiOri Address Stockton CA License No.-5-1-22,6-9—Phone 209 465- 712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION $I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ElOpen Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout V ' 1 1 Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 0 Well Destruction IR Well Diameter 2-i nCh Sealing Material (top 50') RantCl i to—Pex T. r urkett-2 Q (3 wells ) Depth 50 feet Filler Material (Below 50') Not applicable 7� TYPE F SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation w rve: Residence— Commercial_ Other Number of living unr Number of bedrooms Character of soil to a depth 3 feet: Water a depth 1 SEPTIC TANK 0 Type Compartments PKG. TREATMENT PLT. ❑ Method of Dis os l Distance to neare Foundation Property Line PAY EN-1 LEACHING LINE ❑ ngth of Ii s Total length/size RECEIVED FILTER BED Distance to ne st: Well Founda�n Property Line OA UIN COUNTY SEEPA ITS I I Depth Size Number PUBLIC HEALA.L—� LTH DIVISION SU S Ll Distance t nearest: Well oundation PropertoWON 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 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 rnanner as to become subject to workman's compensation laws of California."Contractor's 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 a Jornia." The applica t must call for !I required inspect( to drawing on reverse side.ja Project Geologist Date: Signed X 8 ` R DEPARTMENT USE ONLY Application Accepted by Daten� Area Pit or Grout Inspection by Date Final Inspection by_�I A _ Date Additional Comments: W&L ?b� �d ❑ Stk 466-6781 ❑ Lodi 3&4&21 Cl Manteca 823-7104 V ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 511co FEE AMOUNT DUE AMOUNT REMITTED cK RECEIVED BY DATE PERMIT NO. INFO �CASH +.EH13-241REV.i/x5f EH 14-2e