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, 51, e_a pler,on — qu9, 31 19�� APPLICATION a � SPN JOAQLI"; LOCA �� c �.-.� 1601 E. HAZE TON AV �) OCKTON, CA PERMIT N0. � +�•`' Telephone (20 -67'JUL 2 5198 �tijJ !✓ 3 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in TriplLOCAL Application is hereby made to the San Joaquin Local Health DistricttiCALpW4 FS c t 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 5329 E IgSA �lQ -/YCa..-�.� Subdivision Name Owner's Name /�j'�ljur ke- blU fVa ft $328 Z Awm pa Aa-,OX�'�hone Contractor's Name Purviance Drillers DrilliCorp, License No. Phone DJ-q46 I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 71 Industrial U Open Bottom F-1 Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Wj Irrigation Approx. [] Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump T"jl la H.P. ;2 5—' State Work Done ehdnll0_ LS 01✓/s Well Destruction F-1WellDiameter Sealing Material (top 50') 4d , Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is co 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 ❑j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line P DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑1 Depth Size Number SUMPS L-1 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. 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 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 compensation laws of California." The applicant must call fo 111ons. Complete drawing on reverse side. q,4 rl Signed X Title: S'�yJP��r�A Date: 1-.2 Z. A DEP AR T USE ONLY Application Accepted by Area d ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO £H 13-24 REV. 10/82 10/82 500 14-26