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ra-z. qz;a- a t APPLICATION FOR PERMIT r f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ` (Complete in Triplicate) Application is heteby 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. Jon Address 1800 West Church Street �;ty 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 D&F Drilling Address Rancho Cordova, CA 95742License No. 519428 Phone (916) 631-95 6 TYPE OF WELL/PUMP: NEW WELL � WELL REPLACEMENT ❑ DESTRUCTIO ElPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 146h r/IItll LtIG6j DISTANCE TO NEAREST: SEPTIC TANK 150' SEWER LINES 150' DISPOSAL FLO.>50' • PROP. LINE .;1110 - FOUNDATION AGRICULTURE WELL 1200' OTHER WELL 5C' PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R Dia. of Well Casing r' i ❑ Domestic/Private 19 Gravel Pack ❑Tracy Type of Casing Schedule 40 PVC Specifications 1 11 Public KI Other Monitoring Delta Depth of Grout Seal 15.5' Type of Grout 5Jm 6'.eent wi.th, % Be"1i`toniC I I Irrigation 29.3...r Approx. Depth I I Eastern Sur(ace'Seal-f'talkr4L� _ Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material 66p 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other l Number o1 living units: Number of bedrooms E Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG.TREATMENT PLT.❑ Method of Disposal t Distance to nearest: Well Foundation Property Line { LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line III SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to neatest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 Di9vict. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this pern it is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, Ishall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on r vases�ido. ' Signed%`t.�Z.Z04 I � ��M Tide:-�_,�/Qt�le Date: I FOR DEPARTMENT USE ONLY r Application Accepted by Date ✓� ; Yx��'�I• �i Inspection by Date Pi or Grout pection Dat Final In � A lbonel Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 636-6385 • - - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 NFO AMOUNT DUEAMOUNT REMITTED R RECEIVED BY DATE PERMIT NO. �.EN WMIREV.vxsiJ7heZ9. I