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a f -3 � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �.� ��• �P,,'� (Complete in Triplicate) �NCP�-�(S Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d e 1� iSG�epplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and l�i of t e San Joaquin Local Health District. t Job Address 2900 W. Navy Drive City Stockton Lot size 1 . 785 acrespM Owner's Name Union Pacific Railroress 1416 Dodge St. , Omaha , Neb.Phone (402) 271-500 � Contractor Spectrum Address 2825 E . myrtle St. C 7—.5.:1:2268 Ph0ne(209) 465-;8 22 . Y License o:_ -_.. .. TYPE OF WELL/PUMP: NEW WELL)% WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR"Cl OTHER ❑ w; DISTANCE TO NEAREST: SEPTIC TANK 0 f t SEY6.1I TINES �5 0 f t DISPOSAL FLC,:'�1007�iOP. LINEl--3-'-,-7 ' , 10 r fOUNDATION5'6-£-t-. 1-6 fdGRICULTURE WELL>'l-OO f rOTHER WE&O-L'3'3 r" PITS/SUMPS 100 f`t� '- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑:.Open Bottom ❑ Manteca Dia. of Well Excavation 10 Dia. of Well Casing 4 in Z Domestic/Private M Gravel Pack ❑ Tracy Type of Casing PVC Specifications B�t tonite f 1 Public n Other P9 Delta Depth of Grout Seal 2-4 ft . Type of Grout U r r y } i I Irrigation Approx. Depth I I Eastern- Surface Seal Installed b T-remie;, ithr;0u.gh hollow Stern t t g 15-2-L).flap P v auger : � Repair Work Done ❑ Type of Pump H.P. State Work Done -r Well Destruction ❑ Well Diameter. Sealing Material (top 50') Depth ' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I i INo septic system permitted if public sewer is availablewithin 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: 1 Water table depth t SEPTIC TANK ❑ Type/Mfg,( Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ( t i LEACHING LINE ❑ No. & Length of lines Tota! length/size F _. ..FILTER BED ❑ Distance toy nearest: Well Foundation Property Line i I SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line �'DISPOSA OiVDS a. C]f9� --,r} .�• ,; -=�.:.�-—.t _ ,. � .--y-�•-:-�,,,.:-..��....�.�,..�-�— �� -r�--�,:r.�:.—:i t 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 fallowing; "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." I The applicant ust cal for II re inspections. Complete drawing on r vers side. t Signed Title: FDD -It Date: l FOR DEPARTMENT USE ONLY r { Application Accepted by Date Area i Pit or Grout Inspection b Data`s Final Inspection by Data i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 p Manteca 823-7104 ❑ Tracy 835-6385 e `oplicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO: 5,