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II APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIST 1ICT 1601 E HAZEL T ON AVE , STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 rn cornp(rance 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 bistnet Job Address ' City Lot Size PM Owner s Name Address Phone 213 923-9876 Contractor SPECTRUM EXPLORATION, INC Address 2825 E. MYRTLE ST, STOCKTON C-57 ' License No 512268 249 498-2720 TYPL OF WELL/PUMP NEW WELL ❑ Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST SEPTIC TANK OTHER ® FOUR 20 FOOT SOIL --. r _ SEWER LINES _T/a_� DISPOSAL FLD n/a PROP LINE BORINGS FOUNDATION AGRICULTURE WELL n/a OTHER WELL n a PITS/SUMPS _n�a INTENDED USE TYPE OF WELL PROBLEM AREA ] Industrial CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia of Well Excavation Inc es C) Dgmesuc/Private ❑ Grave! Pack Dra of Wel( Casing n/a f ' Public 0 Tracy Type of Casing f� Other f� Delia Specifications Depth of Grout Seal ' Type of Grout 1 1 Irriddtion Approx Depth f I Eastern Surface Seal Installed by drilling contrndtor Q ite Repair Work Done L7 Type of Pump n/a H P �a Well Destruction t] State Work D6ne _ n/a 16limeter � Sealing Material (top 50) n/a Depth 20 feet Filler Material (Below 50') n/a TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installan n will serve ResidenceCommercial— Other available within 200 feet ] �^ Number of living units Number of bedrooms Character of soil to a depth of 3 feet SEPTIC TANK ❑ Type/Mfg Water table depth PKG TREATMENT PLT ❑ Capacity. No Compartments Distance to nearestMethod of Disposal WeN Foundation Property Line LEACHING LINE 0 No & Length of lines FILTER BED ❑ Distance to nearest Well Total length/size N/A Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS N/A L1 Distance to nearest Well DISPOSAL PONDS [� Foundation Property Line�_- �' I hereby certify that I have prepared this application and that the work Will be done in accordance with rules and regulations of the San Joaquin Local Health District San Joaquin county ordinances state Paws and 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 tion laws of California certifies the following f certify that in the performance of the work for which this permit is issued I shall employ persons subject to workman s compensa The applicant must call for all required inspections Complete drawing on reverse side Signed X /L Zir� Title PROJECT GEOLOGIST Date 12-18-87 FOR DEPARTMENT USE ONLY Application Accepted by 1 1i Pit or Grout Inspection by Date Area Date Final Inspection by Additional Comments Date C Stk 466 6781 ❑ Lodi 369 3621 , Applicant Return all copies to Environmental Health aPerm t/nteca Sere cess 1601 E3 7104OHazeiton Tracy 835 3ve , P 0 Box 2009 Stk CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK RECEIVED BY DATE CASH PERMIT NO a EH 13241REV 4 n5� EH 14 26