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• APPLICATION FOR PERMIT • 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) Application is Imlehy 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 116 Contractor B&F Drilling Address Rancho Cordova, CA 95742 icense No. 519428 Phone (.916) 631-95 i6 TYPE OF WELL/PUMP: NEW WELL I WELL REPLACEMENT Cl DESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.X It16h I-I'JY-Ihy Oe-t1 DISTANCE TO NEAREST: SEPTIC TANK >50r SEWER LINES >50' DISPOSAL FLO.>50r PROP. LINE >'IOr FOUNDATION AGRICULTURE WELL >200r OTHER WELL 5Or PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I Industrial CI Open Bottom Cl Manteca Dia. of Well Excavation 8" Dia. of Well Casing ___2" 1 1 Domestic/Private 7t1 Gravel Pack I I Tracy Type of Casing. Schedule 40 PVC Specifications r I'I Public XI Other Monitoring Delta Depth of Grout Seal 1.S1i _ Type of Grout_Cement with I I Irrigation 29.5'Approx. Depth I I Easton Surface Seal InstatWd-by _. _ ___57 Bentonite___ Repair Wolk Done I 1 Type of Pump H.P. _ _ State Work Done Well Destruction I 1 Well Diameter Sealing Material (top 50'1 __— Depth Filler Material (Below 501 TYPE. OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTHOCTION I I INo septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence__ Commercial_ Other _ YS Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK IT Type/Mfg Capaci(y___ No. Compartments L PKG. TREATMENT PLL 11 Method of Disposal Distance to nearest: Well Foundation= Property Line (� LEACHING LINE Ll No. & Length of lines _ __—_ Total length/size FILTER BED ( I Distance to nearest: Well Foundation _ _ _ Property Line n r_ SEEPAGE PITS I I Depth _ Size _._ _ .—_ Number SUMPS I I Distance to nearest: Well_ Foundation Property Line DISPOSAL PONDS Ll 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 verse side. Signed X /��iy[.p� Title: Y✓Y(Qi�✓(ry Date: L=16-1-7�+,0 FOR DEPARTMENT USE ONLY Application Accepted by � � Date Area 3`7 / / Pit or Grout Inspection by — Date Final Inspection by Date Additional Comments: 11 Silk 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, Sik., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. EI11314 fRFV,Iia 1) 73 �1� r 1'-�,-j•3b En 1418 –V _,>—s l �>�— ��1/ l0 1