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APPLICATION FOR PERMIT * SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091466-Ml r1 YEAR FROM DATE ISSUED L� $AN jolt 0�t't4•tea.aacws�,�s -- -- .,_ - 9W.laj)fVjg*Complete in Triplicate) Application is t District for a permit to construct and/or install the work herein described.This application is Lmade ocal in c" � 549 for sewage or No.IBM for well/pump and the Rules and Regulations of the San Joaquin J,bAddm"1515 Weber Street city Stockton Lot Size PM 201 Mission_ Street, Suite 250 Owner's Name Santa Fe Pacific Realty Address San FrAn Isco`-CA 94105Phone 2825 East Myrtle Street Contractor Spectrum Address Stockton, CA 25ZQ5--_License No.C-57-51226 , TYPE OF WELL/PUMP: NEW WELL 91 WELL REPLACEMENT ❑ DESTRUCTION El onitoring Wells PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ MW-1, MW-2, MW-3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES unknown DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wag Excavation 8-" Dia.of Wen Casing 911 i ❑ Dornes6clPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Schedule 40 PVC Specifications (7 Public (I Other Delta Depth of Grout Seal 15 t Type of GrouIbe oIIC I I Irrigation 0 Approx. Depth I I Eastern Surface Seel.Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Wei Destruction ❑ well Diameter 2" Sealing Material (top 50') Bentonite cement Monitor Dept 30' Fuer Material Wallow W) TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAER/ADDITION i I DESTRUCTION 1 I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence,,.- Commercial Other Number of living units: Number of bedrooms11 'r i „vr vs t' I Char of sto a depth of 3 feet: : . water taba .deput recMoil SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Dill' 0 1989 Distance to nearest: Weil Foundation Property Line LEACHING LINE ❑ No. 6 Length of fines _ Total length/site 11 - triL" FILTER BED ❑ Distance to nearest: Wen Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distanes to nearest: Wed Foundation Property Line DISPOSAL PONDS ❑ I hereby ONOY that I have prepared this applicatiot and that the work will be done in accordance with San Joaquin county ordinances. state laws, and rules end regulations of the San Joaquin Local Health 03trict. Horne owner or licensed agerx's signature certifies the following: "I car*that in the performance of the work for which this permit is issued. I shag not ampfoy any person in such mariner as to berortte&AWt to workman's compensation laws of California."Contrsctoes hirbV or sub-contracting signs true certifiers the fogowke:"I certify that in the performance of the work for which this pen*is issued,I shah employ persons subject to workman's compensa- tion laws of California." The call for to tions. Complete drawing on rnrersq sb Signed Title: Date: f r DEPA U$E Application Accepted by Date r,/ Area I Pit or Grout Inspection by Date Final Inspection by Datem Addkk al Comments: ❑ S* 466.6781l ❑ Lodi 383621 ❑ Manteca 823-7104 ❑ Tracy 836.6366 Appticent-Rattan ail copies to: Envirpnine ttal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FU CK 9 WFFO AMOUNT DUE AMOUNT REMrtTEpAh .z/^- RECEIVED B DATE PERMIT I�10. .-E1in*sslRkv.,ise, �&0 -5 C/ 0-2- y