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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 hereby made to the San Joaquin Local Health District for a permit to construct and/or install then cri . This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump ane Rues gulati0 of the San Joaquin Local Health District. Job Address West Weber Avenue and North Lincoln Street City Stockton bre Sze PM 425 North E1 Dorado Street Owner's Name Stockton Redevelopment Agency Address Stockt ani (A 952n2-1997 Phone (909) 944-8-538 Contractor Wayne Drilling Company Address P.O. Box 726, Lincoln, LL-956i-$cense No.376345 Phone (916) RRr97A7 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ Vapor Survey PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 borings/monitoring 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 Dia. of Well Casing 2—inch ❑ Domestic/Private (N Gravel Pack ❑ Tracy Type of Casing PVC Specifications ("1 Public M Other F1 Delta Depth of Grout Seal 8 feet Type of Grout ceMent/bentorli to I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Sum' Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Monitor Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I F1,[FAiR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms �1 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 t LEACHING LINE ❑ No. & Length of lines Z 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 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 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 m all r all required inspections. Com lete drawing on reverse side. Signed X - Title: Project Geologist _ Date: 6/22/89 �PR �DEPA HENT USE ONLY Application Accepted by - _' Date � i" Area. � y� ��'-"� /�� =-l-Sf., p � ! Date / Pit or Grout Inspection b / Date Final Ins ection b / ' '" Y" n 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 INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. EH13-24(REV.I/H 5) 5 (,�(� S l,T LI `7 Q [� (�