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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 t 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 the work herein described. This application is made in compliance with San Joaquin'Counry Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. f Job Address 5733 Leonardini Rd city Stkn Lot Size 20 Acres PM I. . Owner's Name Kevin SangiAnettZ_ Address same Phone 931 _1766 Contractor Clark Address2024 E. Charter WaV License No.371 560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [X DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 75 1 SEWER LINES DISPOSAL FLD. 1 00 1 PROP. LINE +cn0 I FOUNDATION AGRICULTURE WELL OTHER WELL 25 1 PITS/SUMPS t INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 Dia. of Well Casing 6 5 8 rr Domestic/Private Gravel Pack ❑ Tracy Type of Casing Steel Specifications #1 2 r f'] Public f_1 Other ❑ Delta Depth of Grout Seal 50 Type of Grout 9 sack I ] Irrigation --.-Approx. Depth 11 Eastern Surface Seal installed by C)ther_s _ kf Repair Work Done ❑ Type of Pump H.P. State Work Done l Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is l available within 200 feet.] \J S Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms V-' ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size _ Number SUMPS is Distance to nearest: Well Foundation Property Line DISPOSAL PONDS. ❑ 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. t 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 applica s c I r r ire i pections. Complete drawing on reverse side. Sig x Title: Clark Well , Inc. VP Date: 17 July 1989 FO EPARTMENT USE ONLY J 7—AP-1)901 1 ! Application Accepted by DateArea 7� Pit or Grout Inspection by S' Date t Final Inspection by Date L' Additional Comments: lov a `l� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 M Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I1 V11\ FEE ' INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-NO. I +.EH 13241REV.t/r55f 7/1Cd EH 14-20