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I ' 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 made H compliance with San Joaquin County Ordinance No. permit to construct and/or install the work herein described. This application is Local Health District. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Job Address 11651 Palm Lane, Manteca Owner's NameSoLltrlWeSt Hide Co. PCity Lot Size PM 'adlQ%, Box 2083, Manteca Ca. 9533 ContractorPUr_ Vlance Drillers hone AA 1�-s• ,P.0.Box 64,Linden License No. 377923 TYPE OF WELL/PUMP: —__Phone 887-3554 NEW WELL C7 WELL REPLACEMENT ❑ PUMP INSTALLATION ❑ DESTRUCTION DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public ❑ Other (1 Delta Depth of Grout Seal Type of Grout 1 1 Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction )QC Well Diameter12" & 8" Sealing Material (top 50') -AC-f!4-ca Grout Benseal Depth( 30 93 Filler Material (Below 501 of to of TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ILA Number of living units: Number of bedrooms 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 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 SUMPS Cl 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 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's compensation laws of California." Contractor's subject to workmanis ng ompensr certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." The applic must c �fo qui ed inspections. Complete drawing on reverse side. 8�21�89 Signed Title: President Date: FOR iyPA USE ONLY Date `� ? z A a Application Accepted by C�Af!!5!B Pit or Grout Inspection bDate Final Inspection b �� Dat y Dale Additional Comments: 4ti��i��`(' ❑ 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.0- Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH . EH 13.24 IREV.I/m51 '?, EH 14-26