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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 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 1800 West Church Street City Stockton Lot Size PM 800 W. Church Street Owner's Name Newark-Sierra, Inc. Address Stockton, CA 95203 Phone (209) 466-5251 3663 Omec Circle #6 Contractor B&F Drilling Address Rancho Cordova, CA 9574?ticense No- 519428 Phone (916) 631-95 6 TYPE OF WELL/PUMP: NEW WELLWELL REPLACEMENT ❑ DESTRUCTI0 ❑ PUMP INSTALLATION ©R SYSTEM REPAIR ElOTHE MSI( .ren5 (.rle;rl DISTANCE TO NEAREST: SEPTIC TANK 150' SEWER LINES >50' DISPOSAL FLD.5Q}"..= PROP. LINE 24W - FOUNDATION AGRICULTURE WELL �200r OTHER WELL 501 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Orr Dia. of Well Casing 1 2" ❑ Domestic/Private U] Gravel Pack ❑ Tracy Type of Casing Schedule 40 PVC Specifications ) I'] Public WOther MonitoriIT$Delta Depth of Grout Seal 15.51, .1 Cement -with ,_.,. Type of Grout J�- ,,.:.- I I Irrigation 29,-5-.'Approx. Depth l I Eastern Surface'Seal lns,'atled by 5� Belltonit Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction © Weil Diameter Sealing Material Stop-50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CI Method of Disposal t 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 SEEPAGE PITS I I Depth Size _ Number SUMPS Cl Distance to neatest: Well Foundation Property Line DISPOSAL PONDS 0 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 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 must call for all required inspections. Complete drawing on r verse side. Signed X Title:" # Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date �l ld �itionalComments: pection - � Dat t✓ Final Inspection by Date � Z d ASO ❑ 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT"NO. +.EH 13-24{REV.t/e r,i - - EH 14"zs