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�a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. %9 M sb� Job Address Swanson Roi3C1 City Mantpra Lot Size 5 AcQrc PM Owner's Name Jerry Anders, n Address 11596 S Union, F'renchCamp Phone239-2768 Contractor Pflantin Pump & S Address 5 rt2t c3 Rnarr""""y"`""" '�_ License Nn.-3 License Phone — TYPE OF WELL/PUMP: NEW WELL N WELL REPLACEMENT"M? ' r DESTRUCTION ❑ PL1N(P IfVSTALLATIO[ti"®"" SYSTEM-REPAIR '❑' OTHER-fp DISTANCE TO NEAREST:.SEPTIC TANK 100'+ SEWER LINES 100'* DISPOSAL FLD.1 Q0'+ PROP. LINEt FOUNDATION 251 AGRICULTURE WELL —QM— OTHER WELL NONE PITS/SUMPS IIQI�IE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation'• Dia. of Well Casing ''6 5/8 r ` V,f k Domestic/Private 91 Gravel Pack 17 Tracy Type of Casing Sf&l_J Specifications (`I Public Cl Other C 1 Delta Depth of Grout Seal ° r t 50 ' + Type of GroutBentOnite _ i I Irrigation Approx. Depth I I Eastern Surface Seal installed by _ RepairWark Done CK1 Type of Pump SL11JI11 H.P. 3 { _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I" DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installationwill serve: Residence— Commercial Other Number of living units: Number of bedrooms s is Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ "Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 - Method of Disposal Distance to nearest: Well Foundation 4 -'t Property Line LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance�to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number i M SUMPS CI Distance'to nearest: Well Foundation Property Line 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 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." 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 compensa- tion laws of California." The apphanj st call for all required inspections. Complet drawing on averse side. Signed X Title: / ► � A Date: k i FOR DEPARTMENT USE ONLY f. Application Accepted by Date ` �+ `� Area V Pit or Grout Inspection by Date 944L-N Final Inspection by Date�T Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3&21 ❑ 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 INFO AMOUNT DUE; AMOUNT REMITTED CK GASH RECEIVED BY DATE PERMIT'NOy./ +.EH13-24(REV.1/x5) EH 1428 •) L ' ''J,J