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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone {209} 466-6781 PERMIT EXPIRES TYEAR 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 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 XWest e r AVS e>1ii-e_1-and North Lincoln Street city Stockton Lot Size PM 425 North E1 Dorado Street Owner's Name Stockton RedeyeloT_ment Agency_. Address Stockton, CA 95202-1947 Phone (909) 944-8538 Contractor Wayne Drilling Company Address P.O. Box 726 Lincoln cense No.376345 Phone989-9747 TYPE OF WELL/PUMP: NEW WELW WELL REPLACEMENT ❑ DESTRUCTION D Vapor Survey PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 borings/m nitoring wells 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 LSI Gravel Pack D Tracy Type of Casing PVC Specifications f`1 Public ❑ Other D Delta Depth of Grout Seal 8 feet Type of Grout Celi]Mt/benton to I I Irrigation ---Approx. Depth I I Eastern. Surface Seal Installed by terry _ 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 rte TYPE OF SEPTIC WORK:. NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is 0 available within 200 feet-1 C_ Installation will serve: Residence— Commercial— Other Q 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 1 LEACHING LINE ❑ No. R Length of lines Total length/size (1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS 11 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: "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 J. 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. Cam lata drawing on reverse side. Signed x - _ Title: _Project_ Geologist Date: 6/22/89 DEPA _EYT USE ONLY Application Accepted by Date �) Area Pit or Grout Inspection by Date � Final Inspection b net,//- Additional ate /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 REMITTED K H RECEIVED BY1. 1 DATE PERMIT'N0. INFO ,l y 1gq- EH EH13-24(REV.riNs7 �5'v� J3` 1 ��14-20