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• APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROMDATE 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. 1852 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address 4610 Fine 'Road ` City Linden""- Lot Size PM Owner's Name Pete Winston Address 4610 Fine Roadp Linden -'sone 887-3523 Contractor Purviance D'Cillerliddress P. 0. BOX 648 tindWbnse No. 377923 Phone887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATION,__ _ SYSTEM REPAIR,❑ --_- _OTHER ❑ _ _- ' 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 r . ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 3KDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal, Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed14y Repair Work Done ❑ Type of Pump Sub H.P. 2hp *11 State Work Done new pump On new Well Destruction ❑ Well Diameter Sealing Material (top 50') well ._ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑. DESTRUCTION Q (No septic system permitted if public sewer is V available within 200 feet.) Installation will serve: Residence—! tCommercial__ `Other.- T Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: t s..,+ Water table depth SEPTIC TANK ❑ Type/Mfgpp Wit' 3 Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal r f,. > Distance to nearest: Well Foundation' Property Line LEACHING LINE Q No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size ,. Number SUMPS ❑ 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 with San Joaquin county ordinances;state laws, and rules and regulations of the San Joaquin Local Health District. J,5-. i 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 compensa- tion laws of California." The ust call f r a requir inspections. Complete drawing on r verse side. 55- ed Title: Date: 4 FOR DEPARTMENT USE ONLY , Application Accepted by Date�/ 2—`672 Area O Pit or Grout Inspection by Date Final Inspection by Date r. Additional Comments: - - ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Heaith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNTtREMITTED RECEIVED BY DATE PERMIT"N0. INFO y + EH 13-24(REV.1/85) V7/� EH 14.28