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APPLICATION FOR PERMIT PAY MENT�/ REGE�VED 5AN JOAQUIN LOCAL HEALTH DISTRIG`i" vv, 1601 F. HAZELTON ON AVE., STOCKTON, CA AP2 `1 Telephone Q091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEAD-M (Complete in Triplicate) PERMITISERVIGES 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 44 South Wilaon— ay City Stonkton Lot Size PM San Joaquin County 222 East Weber Owner's NameCeneral Services Address Stockton. CA_9$202 Phone (209) 944-3679 Spectrum 2825 East Myrtle Avenue Contractor Exploration, Inc. Address Stockton CA 95202 License No.C-57512268 Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER R Soil Borrings (6) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia, of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public f7 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 11 Type of Pump H.P. State Work Done_ Well Destruction Cl Well Diameter _ Sealing Material stop 501 backfill sand/cement slurry 20 ft. to Depth Filler Material {Below 501 surface TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIWADDITION l I DESTRUCTION I I (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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well -- Foundation Property Line LEACHING LINE 1-1 No. & Length of lines Total length/size FILTER BED [7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS I 1 Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS L1 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 Diltrict. 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 shalt 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 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." The applicant s all for all requiresins ctio Complete drawing on reverse side. Signed X Title: Date:Date: r D 9 'MENT USE ONLY Application Accepted by __ ��=�' F �_ � .j� Pit or Grout Inspection by _ Date Final Inspection b _ ,� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 EI Tracy 835-6385 Applicant - Return all copies to: Environmental Hesith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE!NFO AMOUNT DUE AMOUNT REMITTED RECEIVED RECEIVED BY DATE PERMIT'NO. + EH 13.2 (REV,r i H 5) EH 11-28 .d 0