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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. 1962 for welllpump and the Rules and Regulations at the San Joaquin Local Health District, Job Address Cal 23N6Lot Size PM Owner's Name Address ra Phone ContractRuryla]p(: Dri] Jl Address P. 0. License No. 377923 Phone. 87— TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X 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 ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation I[] Dia. of Well Casing 10 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casirjg Specifications �^ M Public ❑ Other Cl Delta Depth of Grout Seal — Type of Grout _ 6� X Irrigation 4QQArpprox:Depth I I Eastern Surface Seal Installed�by - Q Repair Work Done ❑ Type of Pump ZiU H.P. 2hp Work Donen PW wP]_I-I new PURIP I Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material IBelow 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RFPAIR/ADDITION I 1 DESTRUCTION I 1 avlailablseptic systemithin emitted if public sewer is r eet Installation will serve: Residence_ Commercial__ Other �1 Number of living units: Number of bedrooms (� 1 Character of soil to a depth of 3 feet:; Water table depth i SEPTIC TANK ElType/Mfg Capacity y No. Compartments t Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance io 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. 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 la lifornia." The pplica m st all for all required inspections. Complete drawing on reverse side, Signed +✓ Title: Dan Purviance, Presiderb&e: 10/28/88 O E #ENT USE ONLY Application Accepted byAL,di, Date " Area 0 PP P Pit or Grout Inspection bDate Final Inspection by Date �• Additional Comments: 0 Stk 466-6781 Man 523-7104 ❑ Tracy 835-6385Applicant Return all cat Slrvices 6 s=alt vp��P�O�f1B0StK1�IC �52 FEE MOUNT DUE AMOUNT REMITTED GASH RECEIVED By DATE PERMIT NO. INFO +.EH 13.21[REV. /n 5Y EH 4/-25