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7. f +�Z -d" —e APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 EHAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TY FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 X742 • Clements Rd' city Lot Size PM lPhone 1. owners NameLewallen Land tle Address 7 ContractorFUrva.��E' Drillers+�t3r;t� 15 70 7 E k:jnnse No.X9.23—Phone — 994 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION SYSTEM REPAIR 13OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE —E <::►; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ;r , "'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `ae 0 1'nclostrial X Open Bottom ❑ Manteca Dia- of Well Excavation 600 Dia. of Wel! Casing ❑ Domestic/Private ❑ ave/ Pack ❑ Tracy Type of Casing Specifications •2�JQ 1`1 Public 71 Ot r ❑ Delta Depth of Grout Seal ri0 ° Type of Grout CPMa l ,Q Irrigation 7500" prox. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ of Pump �u�h H.P. !� — State Work Done Well Destruction ❑ Well Diameter Sealing Materia! I[o13 5. I 'N. Depth Filler Material (Belovi 50') — T-YPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence— Comm tial_ Other kms Number of living units: Number of bedr ms [1� j Character of soil to a depth of 3 feet: Water table depth Capacity-- No. Compartments' SEPTIC TANK_ ❑_ Type/Mfg Y PKG. TREATMENT PLT ❑ #� Rc_ ,- Method of Disposal Distance to nearest: W I ?'i.- asaFoundatibn Property Line F� k LEACHING LINE ❑ No. 8r Length of lines LL Y Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I l Depth Size — Number `+ SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 Di§trict. 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 taws of California." Contractor's hiring or sub-contracting signature ,.,,c6rtifies 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 law ia." The pplicant must II r a requ" d in ctions. Complete drawing on r erse side. + Signed f Title: Date: a USE ONLY Application Accepted by O Date "8_TD Area / f Pit or rau Inspection by � Date net Inspection by Date� s 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. Bax 2009, Stk., CA 95201 I FEE OUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. INFO I dg ..EH 1324 IREV.t/n 57 EH 14-26