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} F PAY1D APPLICATION FOR PERMIT IP r- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 5�� ► Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE�ISSUED (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 in t;ompliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ruies and Regulations of the San Joaquin Local Health District. Weston Ranch, Adjacent to 4599 Manthy Road, east of the San Joaquin River, Job Address South at French Camp sioug_1 ..and City Stockton Lot Size 1454,. PM West of Manthy Road (see site location map) (see boring location map) Owners Name Resource Development Address 41 W Yokuts Ave. , -Stockton., mhone - f 2825 E. Myrtle Street C-57-512268 209-948-1345 Contractor Spectrum:- Address Stockton, CA-95205 _License No. Phone TYPE OF WELL/PUMP: NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 4 INTENDED USE TYPE= OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ 8tt Dia. of Well Casing 2 in. ❑ Domestic/Private C5Gravel Pack ❑ Tracy Type of Casing Sch. 40 PVC Specifications 171 Public IX Other n Delta Depth of Grout Seal 2.5-4.51 Type of Grout I I Irrigation UApprox. Depth I I Eastern Surface Seal Installed by 0-2.51 _ Repair Work Done 0 Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter 21t Sealing Material (top 50') Bentonite/Cement Slurry Depth Filler Material (Below 50') Monterey Sand TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION t I DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 0 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 Q LEACHING LINE ❑ No. & Length of lines Total length/size D FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Cal The appiic t m t call for all req actin cti s. Complete drawing own reverse side. / �� Signed X Title: / L/r1 �� Date: FOR DEPARTMENT USE ONLY Application Accepted by _. Date Area Pit or Grout Inspection by ' Date, _. _ Final Inspection by Data Additional Comments: I w ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Sik., CA 95201 t FEE INFO AMOUNT CDUE AMOUNT REMITTED CK H RECEIVED BY DATE ,/yy PERMIT NO. lT + EH 1414-24(pE'V.r i n s1 � vV acs t� �"y .fes...:E31 28 s+"—I [J rY VJrJ 5A