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Teyt�f�e L'or.�p/cion . ung 15 i APPLICATION FOR PER..I ca;. °I �y� F SAN JOAQUi". LOCAL HEALiH ICT 1601 E. HA7ELTON AVE., ST� C�:�,� �ay� �� PERMIT N0. Telephone (209) 466-6781 irt/ PERMIT EXPIRES 1 YEAR FROM DAT EDr DATE ISSUE➢ !3 F,1554! F , w _. it 4Qtj."rid .. 16-("o Iff I (f r ,r (Complete in TriplicaterH'U'L.1-H [YiSTRICT 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 Regulati ns of the San oaquin Local. HealQtt,h D/i;trict. Imo. [ d .:Z i S /y1..lbd4xa�e p 8 53027 Job Address � I Owner's Name ' ' ' Has ip, Address I�SQfl E,�ID,�r� �, -L j%,' rer► Phone OVQ?-361 Contractor's Name Puryiance Drillers Drilling Corp. License No. 3'711,13 Phone f3/_q,6,P TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION jJ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Jt[ndustrial. U-Open�Bottom 5—F-1Manteca Dia. of.Well. Excavation:_ U Domestic/Private F-1 Gravel Pack ❑ Tracy Dia. of Well Casing 17 Public (-J Other Delta b f� Type of Casing 1k Irrigation Approx. Eastern Specifications § ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout F-1 Other p Surface Seal Installed by I Repair Work Done Type of Pump ��LP. �Q State Work Done I Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION E) (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot-size Character of soil to a depth of 3 feet:- Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments {�� PKG. TREATMENT PLT. [ Type/Mfg Capacity Method of Disposal ' I SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line f DESTRUCTION 1 LEACHING LINE U No. & Length of lines Total length/size m ^� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth r Size Number �T•�`Y SUMPS L).._Distance to nearest: Well Foundation, Property Line DISPOSAL PONDS �., _ -. • _ _ - .�- , -. M ��(� -s I hereby certify that I have prepared this application and that the work will be done in accordance witk-Sn 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 i5 issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." a 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 compensation laws of California." The appl ' ntmust 1 or 11 requirld inspections. Complete dra ing on reverse side. Signed X c Title: C� P ,� Date: � _� p 7 E RTMEN SE ONLY Application Acc ted ' Area - 03 ._ �] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date [� Manteca 823-7104 l Final Inspection by _ Date r' Tracy 835-6385 k Applicant - Return all copies t Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO $3 - ! a EH 13-24 REV. 10/82 10/82 500 14-26