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f l r 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) f 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 18527 East Walnut Street City Clements Lot size N/A PM N/A Owners Name S . J. Co . Service Address 1702 East Scotts Ave . phone 209 468-3031 Area No. 43 Stockton, CA 95205 Contractor rid ermi Address License No. Phone TYPE WELL/PUMP: NEW WELL [XX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LXX SYSTEM REPAIR ❑ OTHER ❑ ISTANCE TO NEAREST: SEPTIC TANK 150+ SEWER LINES _ NZA DISPOSAL FLD. 1 5f]-I-PROP. LINE -8-5-- FOUNDATION 5 AGRICULTURE WELL N/A OTHER WELL 1_50+ PITS/SUMPS 1.U+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I-] Industrial LJOpen Bottom ❑ Manteca Dia. of Well Excavation^�F'T�F" Dia. of Well Casing 3 0'+ 14 ❑ Domestic/Private XX1 Gravel Pack ❑ Tracy Type of Casing Specifications XIX Public (7 Other CI Delta Depth of Grout Seal 20 - Type of Grout Pir, de - I i Irrigation �flApprox. Depth l 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump _SUbMe_-r_S , H.P, Sn State Work Done Well Destruction ❑ Well Diameter 7-65 Sealing Material (top 501 Per rade Depth 530 ' Filler Material (Below 501 —Per-- TYPE OF SEPTIC WORK: NEW INSTALLATION €.1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is Cavailable within 200 feet.I Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms q� Character of soil to a depth of 3.teet-.- Wafer table depth ' v SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size iZ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth Size Number \ SUMPS Ll 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 r4th)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 laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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�pc�a11_f_or ail r urr in ctions. Complete drawing on reverse side. Signed X - �"` z ` Title: Assistant Civail Engr.. Date: November 26 1989 Dean G. Gilman pARTMENT USE ONLY Application Accepted by Ct `C �. ___-- Date 21- Area 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: � �� C�� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 7racy 835-6385 W {' t}ti ` Applicant - Return all copies to: Environmental Health Permit/Services 1 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE RMt7"No. INFO �/ CASSHH ^J + EH 13-241REV.iiN5r /U.J�OIJ ��dG ��` / f 412