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"-e APPLICATION FOR PERMIT ..Of SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t to t an /or insall the work n described. This cation is made inti lcompliance wr h San J aqu nade to the San County ordinaJoaquin lnce No.549 for sewage orHealth District for a 'No. 1862 for cwe I apump atnd the Rules and'Regulations of the San,Joaquin Local Health District. Job Address 800 West Church Street city Stockton Lot Size 80 acres PM Stockton (209) 466-5251 Owner's Name Gold Bond Building Produgy&ess 800 West Church Street, Phone Rancho Cordova, CA 95742 Contractor B&F Drilling, Inc. Address 3663 Omec Circle, License No. 519428 Phone 916 631-9 46 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 15 boreholes for PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER soil sampling 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 Cie. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public 91 Other,, _ -- C1 Delta Depth of Grout Seal Type of Grout_ �. L I I Irrigation �.APPEOx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I I avtailabetic within system rented if public sewer is .. 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 SEEPAGE PITS I I Depth Size Number SUMPS LI 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: "1 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." Contractoes 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." Theapplicant ust call for all required inspections. Complete drawin se on reveri /JJ^ negional� . gr.—Engineering .. Signed )' /tea' � ("12-A TitWAMPri ran Environmental Date: 3/28/89 games F. Frumm for Michael J. Rogge Management Corp. FOR DEPARTMENT USE ONLY - Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Data .. Additional Comments: ❑ Stk 466-6/81 ❑ 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 AMOUNT OUE AMOUNT REMITTEDCASH RECEIVED BY GATE PERMIT'NO. INFO `. EH 1124 MEN.v.m EN 142a