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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E 'HAZEL T ON AVE., STOCKTON, CA RECEIVED ; I Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED FEB 02 1990 — i . (Complete in Triplicate) SAN JOAQUIN COUNTY Pyya �rt'd1'f175 �i tjon is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal { h A �Xtt1 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump an e I sl Yif oaquin Local Health District. QqT A I 1 (jos' 550' NOR44T OF C/L OF HILDRETH LN. Job Address 60' -EAST OF HWY 99 FRONTAGE RD. EAST City COUNTY Lot Size N/A PM N A EAST BAY MUNICIPAL P.O. BOX 24055 ; Owner's Name UTILITY DISTRICT Address OAKLAND, �• 94623 Phone (415)835-3000 AMERICAN CONSTRUCTION 1038 REDWOOD HIGHWAY, SUITE 2 (415) Contractor AND SUPPLY, INC. J Address MILL VALLEY, CA. 94941 License No. 310599 Phone 381-0838 ,k { TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, N/A SEWER LINES N/A DISPOSAL FLD. N/A PROP. LINE NLA FOUNOATION N/A AGRICULTURE WELL N/A OTHER WELL N/A PITS/SUMPS N1A }INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing- _N/` Q Domesticl Private O Gravel Pack Y `❑ Tracy I Type of Casing NONE Specifications 9lirlltd� ['l Public XXOther } .� l l Delta Depth of Grout Seal 195' Type of Grout SAND C1' i I Irrigation —.-Approx., p TREMIE METHOD 30Q1 De Depth { 1 Eastern 'Surface Seal Installed by - Repair Work Done ❑ Type of Pump N/A H.P. State Work Done Well Destruction ❑ Well Diameter 1 011 Sealing Material (top 501 CATHODIC PROT. Depth 1 300' Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms "r t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l Distance to nearest: Well Foundation Property Line e [ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth a Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS-_ ❑ f ' 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 Diltrict, i 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 compensar- tion laws of California." 1 r The applica mu call for a ired inspections. Complete drawing on reverse side. Signed STEVE MCKIM Title: PROJECT MANAGER Date: 1/22/90 i OR DEPARTMENT USE ONLY 9 Application Accepted by Date ^� L Area Pit or Grout Inspection by ttj Date Final Inspection by �'��,^�� Data Additional Comments: F1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 C] Tracy 835-6385 Applitant - Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 't AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO e + E4413.24(REV.1/M5) Iq f �-`lq 0.�C� EH 14-26 CJ a