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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT V �L 4 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 FEB 2 `3 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �Vbl`)A 4[ CNTA., HFAt- , (Complete in Triplicate) 1�� t to construct and/or install the work cation is madle nt1compliance with Sano oJoaquin Couthe Santy Ordinauin nce No.549 for sewage orealth District for a 'No 1862 for we l//pump and the Rules and hereinR gulations of the San f Joaquin Local Health District, Job Address 110 West Sono ra Street City StOcktcxt Lot Size PM Owner's Name Ci of Stockton t. of Address Qiq Hall Stockton 95202-1997 Phone 2097 Contractor Address License No. /57252 Phone 209--" 712 8 TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t1le SEWER LINES 2600t DISPOSAL FLD. PROP. LINE t FOUNDATION 400' AGRICULTURE WELL OTHER WELL-15W'.— PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing 27 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications ! Other i"Jr ni Ll Delta Depth of Grout Seal 35 .. Type of Grout bMtOYtlte — i'l Public tOr7� I I irrigation _Approx. Depth I I Eastern Surface Seal Installed by Drill - Repair Work Done ❑ Type of Pump none H.P- State Work Done Well Destruction ❑ Well Diameter 8 aches Sealing Material (top 501 =put x Other Depth Filler Material (Below 501 sand d TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system ithin m emitted if public sewer is eetJ Installation will serve: Residence_ Commercial— Other available 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 lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 0 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 Di$trict. 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 mu al for at eq ed inspections. Complete drawing on reverse side. Signed X Title: Project Geologist Date: 24&'90 Appli-ed GeoSyysStems, 4191 P Rd., agent for City of StockG FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date 444�0 Additional Comments: ❑ 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 AMOUNT DUE AMOUNT REMITTEn CASH RECEIVED BY DATE PERMIT NO. INFO +.EH13-24(REV.t/85) 15 EH 14-26