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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 C E-B 0 2 1990 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SAP,! JO?QE3IN Ci?k.1N7Y (Complete in Triplicate) PUBLIC HEALTH SERVICES r.- [�N, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instwwaw i UNL mk4ctm.4f�N9Acation 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. OS'3— 0 e) —p 2900' NORTH OF C/L OF KEI'TLEMEN LANE Job Address 40' EAST OF C/L OF CLEMENTS ROAD City COST Lot Size N/A pM N/A EAST BAY MUNICIPAL P.O. BOX 24055 Owner's Name UTILITIES DISTRICT Address OAKLAND CA. 94623 Phone(415)835-3000 AMERICAN CONSTRUCTION 1038 REDWOOD HIGHWAY, SUITE 2 (415) Contractor AND SUPPLY, INC. Address MILL VALLEY, CA, 94941 License No. 310599 Phone 381-0838 TYPE OF WELL/PUMP: NEW WELL 1KX 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 1,(A FOUNDATION N A AGRICULTURE WELL _NLS OTHER WELL--N/A-- PITS/SUMPS NZ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation OilDia. of Well Casing N/A • Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing NONE Specifications r 1-1 Public �XOther 1 Delta Depth of Grout Seal 1�5 Type of Grout aND tMN I l Irrigation 30tApprox. Depth I ) Eastern Surface Seal Installed by TREMIE METHOD _ Repair Work Done ❑ Type of Pump N/A H,P. State Work Done 7 Well Destruction ❑ Well Diameter 1011 Sealing Material ltop 50•) CATHODIC PROT. Depth 300' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number . SUMPS 11 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health Di'sirict. 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 nots employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contfacting 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 appli can mu call for all r uired inspections. Complete drawing on reverse side. Signed Title: PROJEC`L'_MANAGER _ Date: 1.122/9.0- DEPARTMENT /22/9f(]DEPARTMENT USE ONLY / Application Accepted by Date !�^n� U Area / Pit or Giit Inspection by Date Fnai Inspection by Date' L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO H ♦ EH13-24IREY.1inSYosio EH 14-2