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. a• Z� f APPLICATION FOR PERMIT t ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i� I (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instali 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, 11651 Palm Lane Manteca Job Address � City Lot Size pM owner'sNamesouthwest Hide Co. P-adQelBox 2083, Manteca Cao 9533(k... (hone ContractorPurviance DrillersAA,1p. ,P.O-Box 64,Linden 377923 887-3554 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION M rr1,rJ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ w�IIS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Dia. of Well Casing ❑ Gravel ❑ Tracy Type of Casing I'1 Public 171 Other # Specifications 171 Delta Depth of Grout Sea! I 1 Irrigation --Approx. Type of Grout _ pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P Well Destruction VI Well Diameterl'2 rr & g" State Work Done 1 Sealing Material Itop 50') Acftza Grout BenSt?a1 Depttt�3 r/ 9 3 r Filter Material (Belo w 50'1 •r �� " TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is r Installation will serve: Residence JCommercial Other available within 200 feet.) � Number of living units: Number of bedrooms r A Character of soil to a depth of 3 feet: r SEPTIC TANKWater table depth ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Capacity No. Compartments w Distance to nearest: Well Foundation Method of Disposal Property Line LEACHING LINE ' of lines ` ❑ No. & Lengjh Total length/size FILTER BED ❑ Distance to-nearest: Well1• Foundation Property Line t SEEPAGE PITS i I Depth Size Number SUMPS L] Distance toy nearest: Weil Foundation DISPOSAL PONDS ❑ Property Line j t ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iaws, and i rules and regulations of the San Joaquin Local Health Driltrict. 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 shalt not employ any person in such manner as to become subject to workman's 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 tion laws of California." p y persons subject to workman's compensa- f` The appfi must c fo qur ed ins ctigns. Complete drawing on reverse side, { Signed Title: President r Data: 8/21/89 r "7 FOR PA USE ONLY Application Accepted by n DateZ" A a Pit or Grout Inspection by Date Q Final Inspection b Dat �(J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O- Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED DATE PERMIT-NO. +.EH 13-24(REV,t i s 5) 1 ,EH 1126 3