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�. APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT j`� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 5 �� Telephone (209) 466-6781 DATE ISSUED SRN joAQUIN LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED = HEALTH DISTRICT (Commppjetee in Triplicate) rri pl iicyaatte) �s•q_ Z7 U � Application is hereby made tofthe�San�Joaquin LLo a� 'Freaft D-istr c5 t' ora permit to construct and/or install the work herein ; described. This application is made in compliance with San .oaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local H lth District. Job Address,2 ktl+aa��d'�.+[A, lA a� � Subdivision Name Owner's Name��w� "`�Ad'dEe— r�es �Z�O�. the. S �.odi - 9S�rEp Phone 3&1- !Mf& Contractor's Name Puryiance Drillers Drilling Orp, License No. 3f7 q23 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ly PL4 P Repjqi,I- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v. INTENDED USE , ,TYPE OF WELL PROBLEM AREA - •CONSTRUCTION SPECIFICATIONS - y IJ Industrial, ❑ Open.Bottom []Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack n Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type`of Casing X Irrigation Approx. ❑ Eastern 5pecificatians ❑ Cathodic Protection Depth Depth of Grout Seal � ❑ Geophysical Type of Grout I� ❑Other Surface Seal Installed by Repair Work Done ] Type of Pump Ur 6J H.P. 3 Q State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION ❑ (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 DESTRUCTION ❑ - LEACHING LINE U No. & Length of lines Total -length/size f FILTER BED ❑ Distance to nearest: Well Foundation , Property Line (� SEEPAGE PITS ❑j Depth Size__. Number SUMPS ❑1 Distance ,to nearest: Well Foundation Property Line h DISPOSAL PONDS ❑ '' }. Q 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 Is 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 mush ca 1 a 1 rep,uired inspections. Complete drawing on reverse side. +' Signed X Title: e Date: Q C p 3 I OR D ARTME T USE ONLY Stk 466-6781 Application epted y Area ,__,_.__ ❑ Additional Comment Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date 2 ❑ Tracy 835-6385 Applicant - Return all copies to. vironmental Health Permit/Services 16 E. az ton Ave P.O. Bax 2009, St k., CR 95201 i FEE BASE AMOUNT UE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO Pum t 3 A 10/82 500 EH 13-24 REV. 10/82 14-26