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eLimpte-ll'on Dec. 15' `? . APPLICATION FOR PERMIT „[ 333JJJ SAN JOAQUI" LOCAL HEALTH DISTRICT O�p Y a�G 5��' 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Q� Telephone (209) 466-6781 DATE ISSUED j SAN 3��,tf�i,��:'� ��+CA1- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED liEALT H �`.�,��{��_ (��(/�] {, (Complete in Triplicate) D'�/— / 3V— 4,G Application is hereby made to the San Joaquin Local Health District for 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. 1$62 for well/pump and the Rules and Regulations of the San Joaq,in Local Health District. _ �l n(J 1e-n ,lob Addressd ,S0 � fI $ � �ZQ �'lssl"v�_ ,�' hone Owner's Name ��_ Q/�} � FARM S— Address 0 E License No. Phone 3 Contractor's Name puryiance lerc Drlllina__Conn, TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER DISTANCE TO_NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL D. PROP. LINE] ?' OTHER WELL PITS/SUMPS I FOUNDATION `. AGRICULTURE WELL INTENDED USE Y TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation F F] Industrial U Open Bottom ❑ Manteca Dia. of Well Casing D U Domestic/Private [:] Gravel Pack Tracy Public CJ Other "o,Delta. Type of Casing III Irrigation r' Approx. Eastern Specifications Cathodic Protection " Depth Depth of Grout Seal Geophysical of Grout U Other , Surface Seal Installed by y Repair Work Done X Type ofPump I H.p 5 State Work Done — Well Destruction U Well Diameter Sealing Material (top 50') Depth, a' Filler Material {Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION �I REPAIR/ADDITION �` (No'seepkic tank o seepage. piavaeilableed if withinu200cfeet.) is 1 Installation will serve: `.Residence Commercial Other Number of living units: Number of bedrooms Lot size .. Water table depth Character of soil to a depth of 3 feet. No. Compartments SEPTIC TANK CJ ' Type/Mfg Capacity a - PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION — l No. &-Leri tfi;of lines � Total length/size " ' LEACHING LINE g Propert Line FILTER BED -mDistance to' nearest: Well Foundation y ------ Size Number _ SEEPAGE PITS SCI Depth, __ _�_ ,— t — � --.�--�� Foundation�--. ,_ Property Line SUMPS L� Distance to nearest: Well F `n l .i - 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 folloing: "I certify that in the perform wance of the work for which this ubject ompensation III permitContractor'sshiring orasubncontractingnsignatureln such certifiesnner as to the followirggomelscertifytthatrinathecperrformance ofwthefwork�fornwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." ' The applicant must call r a1 uired inspections. Complete draw. on reverse side. Date: I/r 2 s' itle: 1 Signed ?( .55 `- R DEPARTMENT USE ONLY Area • D Z Gq Stk 466-6781. Application Accepted by Lodi 369-3621 Additional Comments: Date L] Manteca 823-7104 Pit or Grout Inspection Tracy 835-6385 y F Final Inspection bDate ElApplicant - Return all cto: Enviro en al ealth Permit/Services 1601 E. aze t Ave., P.O. Box 2009, St k., CA 95201 1RECEIVED 8Y GATEPERMIT NO. ` FEE BASE AMOUNT DUE AMOUNT REMITTED p� ? i --,. 10/82 500 ° EH 13-24 REV. 10/82 14-26 F