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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AIV1601 E. HAZEL T ON AVE., STOCKTON, CA p y Telephone (209) 466-6781 Piece, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Noy(Complete in Triplicate) Noy 4 oolA �d�ir�+�o�ii� �y made to the San Joaquin Local Health District for a permit to construct and/or install tF yygfJrherein desc ttSThis application is Lompce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the a�� rY�q�o ns of the San Joaquin Loco ealth District. J" �rT'�SrYfRFV' Job Address 800 West Church City Stockton Lot Size PM_.__..,_.._.— Owner's Name Gold Bond Bldg Products Address 800 West Church Street Phone 209 466-525 Contractor Spectrum Exploration Address 2825 E. Myrtle Stocktot-icense No. 512268 Phone_ 465-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ID 3 piezometers 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1nC Dia. of Well Casing 2 inc ❑ Domestic/Private A Gravel Pack ❑ Tracy Type of Casing PUC FT SCh 40 Specifications l'1 Public ❑ Other ❑ Delta Depth of Grout Sea] 12 Feet Type of Grout 5% Bentonit_. I 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by PUMP and Cement Repair Work Done ❑ . Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material ]Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 'I REPAIR/ADDITION LI DESTRUCTION t I (No septic system permitted it 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 ❑ No. & Length of lines Total length/size 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 ❑ 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 no 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 Califor 'a." The applican u call for all r q d in, n Complete drawing onrerev�e eeAside. - Signed X Title: rA•� - L 1 lam 1 FOR DEPARTMENT USE ONLY i'*NVIRONMENIAL HEALTH CIV€SiON Application Accepted by Date rea Pit or Grout Inspection by Da=c �, _ Final Inspection by Date,AM- Additional Comments- 0 omments❑ 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.D. Box 2009, Stk., CA 95201 E � FEE INFO AMOUNTD]UEE AMOUNT REMITTED CK RECEIVED BY DATE[�(� P(ERMIT'NO. +.EH 13-24IREV.iinsi � aac EH 14.26 173 d /- 0 �