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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> = MrT l=Xp�6-�=YEAR FROM DATE ISSUED <br /> twrwr* rs,..w.���c <br /> $AN�UtI�100VNlY�ruao��"�».;,i�Co�m�plete in Triplicate) <br /> MMMONMBA]TIA LHBA THDIM01$..- <br /> Application ise t en�i� District for a permit to construct and/or install the work herein described. This application is <br /> made in camp li a i 544 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Di r <br /> Job Address1515 Weber Street City Stockton Lot Size PM <br /> 201 Mission Street, Suite 250 <br /> Owner's Name Santa Fe Pacific Realty Address San_ Francisco. CA 94105 Phone <br /> 2825 East Myrtle Street <br /> Contractor_ Spectrum Address_Stockton, CA 9520,5License N0.0-57— 1 hone 948-13'A5 <br /> TYPE OF WELL/PUMP: NEW WELL [ WELL REPLACEMENT ❑ DESTRUCTION )Monitoring Wells <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ MW-1, MW-2, MW-3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES unknown DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8" Dia. of Well Casing rr <br /> ❑'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Schedule 40 PVC Specifications r <br /> 1-1 Public I Other FA Delta Depth of Grout Seal 151 Type of Groutbentonite ce ent <br /> I I Irrigation 30_Approx. Depth l I Eastern Surface Seal Installed by Spectrum <br /> Repair Work Done ❑ Type of PumpH.P. State Work Done <br /> 2rr _ <br /> Well Destruction ❑ Well Diameter Bentonite cement <br /> Sealing Material )top 50') " <br /> Monitor1 <br /> Depth 30 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms f'n'I �; .fs 1 •� ; <br /> Character of soil to a depth of 3 feet: Water tabll <br /> :de'pth _ *. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of DiWly0 igagt� <br /> Distance to nearest: Well Foundation Property Line <br /> \Lii VIVJC N I ,l_ F 'ii_t,i, <br /> LEACHING LINE ❑ No. & Length of lines Total length/size n <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line p. <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wel! Foundation Property Line <br /> DISPOSAL PONDS ❑ y, <br /> 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 <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applican t call for all require 'ns ctions. Complete drawing on reverse sid . <br /> Signed X Title: r Date: r <br /> f� *Date <br /> FO )?EPA T T USE LYApplication Accepted by Date reaPit or Grout Inspection byFinal Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , <br /> I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9 DATE PERMIT'NO. <br /> + EH 13-241REV.5rH51 C /•GLZy 1 <br /> EH 14-26 `}'�� 1 <br />