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l; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ff 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i . Job Address 11651 Palm Lane, Manteca City Lot Size PM Owner's NamSouthwest Hide Co. P,adge%s Box 2083, Manteca Cao 9533(�hone Contractop ryiance DrillersAjpp. ,P.O.Box 64,Linden License No. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION jJJcr.T, ;t-�3 f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA1 K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS € INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public n Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction �M Well Diameterl2r' & 8" Sealing Material (top 501 Aqua Grout Benseal Depth7_1 93 1 Filler Material (Below 501 of to of 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other ' n Number of living units: Number of bedrooms V 1 Character of soil to a depth of 3 feet:/ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE 0 No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line ( SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS ❑ I I hereby cenify 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 Di?trict. 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." Contractors 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 laws of California." . t The appli5a.Nnust c fo fqju�ied inspections. Complete drawing on reverse side. Signed Title: President Date: 8/21/89 FOR A USE ONLY Application Accepted by Date Z r-ArAa Pit or Grout Inspection by Date Final Inspection b Datr � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D M taca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., .P.O. Box 2009, Sik., CA 95201 FEEi INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a EH 13.24 IREV.t/A51 2� EH 14-18 C7 LcV—