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I 40W Pike Dene, Suite D, Concord, CA 94520 (4 X71-2387 �f Robert Juncal PLICATION FOR PERMIT +`r f Geologist)1 QUIN LOCAL HEALTH DISTRICT :i AZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 11 IRES 1 YEAR FROM DATE ISSUED l-1 (Complete in Triplicate) GROUNDWATER TECHNOLOGY INC. tl District for a permit to construct and/or install the work herein described. This application is 549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin ;7 � I Job Address -q0 a,,J Silo TA0V_0 )1 /1'.L1/, City 6*1C- 0O Lot Size PM Owners Name 5C Address ;I 1• Z • _ !/1 G,�.....�.P � Phan Contractor lro a+eV_ fc .Address `�y721��r kP , [ ((fir License No. Phon T�Jr d Ii!Z31? TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 4 lam� ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �a�t DISPOSAL FLD. = PROP, L `J r/INE / FOUNDATION AGRICULTURE WELL OTHER WELL__L5__f_tPITS/SUMPS q�I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 44"ad ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! Dia. of Well Casing Domestic/Private ,Gravel Pack i7 Tracy Type of Casing /�U C, Specifications •O Zea ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type f Grout Ce- eA ❑ Irrigation 5pprox. Depth ❑ Eastern Surface Seal Installed by ,rlT � f� Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below.50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I . Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines A, Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size l Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J 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 manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies 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." t Thea applicant must call for all re ed in `i p pe ions. omplete drawing on reverse side. 1 Signed Title: Date: I EPARTMENT USE ONLY Application Accepted by Date ��lv —d fv_ Area 1 Pit or Grout Inspection Date Final Inspection by Date Additional Comments OrStk 466-6781 ❑ �odi 369 3fi21 ❑ Manteca 87i-7104 ❑ Tracy 835 Gi>35 T Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 008 Stk., CA 9520] ,y NFEEAMOUNTDUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"NO. EH 13.24{AEV.S/Bs) ,3s-.0 � (j yoEH 14-26