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APPLICATION FOR PER'i17 SAN JOA.QL;I,' LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) CotKp lit on !-S,- /4 f3 PERMIT NO. DATE ISSUED 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, ,Job Address a/ -5_J? % —S el, Subdivision Name Owner's Name e Address = .,G �� N . �� Qy Rd, Phone Contractor's Name Purv_iante Drillers Drilling Corp. License No. Phone !?3/_ crC.c, 6 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ ^ DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR 1-1 OTHER J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED.USE `, TY?E OF WELL I]-Indusfr:fal� U Open Bottom F I Domestic/Private ❑ Gravel Pack Public' �jOther PROBLEM AREACONSTRUCTION SPECIFICATIONS Manteca r Dia: of Well Excavation F—] Tracy Dia. of Well Casing ❑ Del to 7 , x ,' Type of Casing 'Irrigation Approx. LJ Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal I] Geophysical Other Type 0.f Grout Surface Seal installed by Repair Work Done EJ Type of Pump �� h. P. State Work Done Well Destruction U 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 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK EI Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEM o Distance to nearest: Well DESTRUCTION - Other Lot size Capacity Capacity Foundation Water table depth �.f No. Compartments Method of Disposal Property Line LEACHING -LINE U No. A"Length of lines Total lengthysize- FILTER BED Distance to nearest: Wel''-1 :.'i -:Foundation Property Line SEEPAGE PITS ❑ Depth Size Number- SUMPS Distance to nearest: Well " Foundation " Property Line DISPOSAL PONDS CI ` 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: "1 certify that,in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to worknang 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, 1 shall employ persons subject to workman's compensation laws of California." The applicant mustZ , cal f 2rl required inspections. Complete drawing on re e se side, Signed X t Title: /^eC� t _ Date: 1 1FO A NT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: 40 ❑ Lodi 369-3621 Pit or Grout Inspection by Date LE Manteca 823-7104 Final Inspection by Date %y r��/ V �� L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE. I BASF AMOUNT. DUE INFO EH 13-24 REV. 10/82 14-26 AMOUNT REMITTED 1 RECEIVED BY \A DATE I PERMIT NO. a 1 fa1'13 10/82 500 M%MI