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fi � APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone (209) 466-6781 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 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 11� 12267 Eight Mile Rd o 4 city, Linden. Lot Size PM M;1dve d Owner's Name DeVincenza- Address 12267 E. Eight Mile Rd. Phone Contra ctor'Purviance Dri1ler1_Afdt,Tsj�c. P. 0. Box 64, L-L1g5W 9 NCPa 377923 Phone—887"3554. TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ �.^-.DESTRUCTION PUMP INSTALLATION 7- x''SYSTEM REPAIR ❑' w OTHER D i DISTANCE TO NEAREST: SEPTIC TANK SEWER'CINE S� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial Y1 Open Bottom El Manteca Manteca Dia. of Well Excavation Dia. of Well Casing ' © D mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing steel + Specifications .250 ljruhl c Cl Other f 1 Delta Depth of,.Gro aSoal Type of Gro C@TC1.eYlt:=,.._+ vc - P�Irri anon --aQQprox. Depth I1 Eastern Surface Seal Installed by _ air Work Done ❑ Type of Pumpturb H.P. 40 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50.1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is r available within 2091.feet.l Installation will serve: Residence_ Commercial_ Other c j. Number of living units: Number of bedloms l' Character of soil to a depth of 3 feet: Water table depth tI 'I SEPTIC TANK ❑ Type/Mfg Capacity •= No. Compartments i PKG. TREATMENT PLT. n_ th, Method of Disposal ' Distance to nearest: W Foundation `Rroperty Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .1 SEEPAGE PITS 11 Depth Size Number � f SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS EJ 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. 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(tiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." • Th applicant call o II required inspections. Complete drawing on reverse side. " } Signe Title:Corp. Secretary Date: 1/30/91 i FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or C.•'t Inspection by Dattt�__�qI Final Inspection bye Date / t z Additional Comments: ❑ Stk 466-6781 D Lodi 369-3621 nteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT fDUrE�7� AM�OUNNT REMITTED CASH CK 4 RECEIVED BY DATE QPERMIT NO.J +.EH 13-24{REV.1/H 51 "'�C!" \7 {�(n_ `� ^ 1 '] \' \+ • i i tN , EH 14-28 ry