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C�D�Ido le-tt 9n al . 5r (� H APPLICATION FOR PERMIT 57—-2 1-�3 p q p SAN JOAQUiN LOCAL HEALTH DISTRICT MAY 2 3 1983 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �— (41 � Telephone (209) 466-6781 SAP) JOA QUIN LM,�L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED � a2 HEAL ffi—DIS �a��i � ..�- ,(Complete ;in-.T iplicate) QQ� p0 0 Replication 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 ,loo in Local Health Dist ict 1J Jab Address h-►`�, S -� kd. ,31►-��. c�QS�g� /Serle-Qc fid, Owner's Name Address A 3 Rvj(�/.Lcq a M,9-�,Dphone Contractor's Name �Purviance Drillers Drilling Corp.License No. ? I�Z3 Phone TYPE-OF-WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ,� SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W r 'N ON. AGRICTURE WELL OTHER WELL PITS/SUMPS ' - 1 UL INTENDED USEY TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial = :,.,.'U Open':8ott6m'-.r x 0 Manteca' - ;0ia. of-Well Excavation-- L1 Domestic/Private 'F ]-Gra•vel Pack Tracy Dia. of Well Casing 17 Public [_1 Other Delta Type of Casing y Irrigation Approx. Eastern d U Specifications ❑Cathodic Protection Depth r � Depth of Grout Seal 1 Geophysical lJ Type of Grout 0 Other Surface Seal Installed by Repair Work Done.❑ Type of Pump 4� H.P. �Q State Work Oone Anna Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 1. available within 200 feet.) Installation will serve: Residence _ Commercial _ Other ; Number ofliving units: Number of bedrooms Lot size "Characte"r of soil tv a depth of 3 feet: - " ti _w-r _ Water' table depth - ' SEPTIC TANK -D�—Type/Mfg "'`""—" '—'Capacity No.' Compartments x PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well a Foundation Property Line DESTRUCTION ❑ ` y LEACHING LINE U No.' & Length of lines. Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ^SUMPS ��' ^Distance to`nearest: Well =Foundation ,Property L"ine 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� 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, I shall employ persons subject to workman's compensation laws of California." t The applic must c 11 11 required inspections. ; Complete drawing on'rev erse side. Signed X _ �... A ' Title: " Date: F R DEPARTMENT USE ONLY Application Accepted by Area C) 5tk 466-6781 Additional Comments: Lodi 369-3621 ^� Pit or Grout Inspection�by Date � Manteca 823-7104 Final Inspection by , Date Tracy 835-6385 r Applicant - Return all copiesir nmental .alto Permit/Services 1601 E. IaPelnAve P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. � INFO ��e_ Gx �3 EH 13-24 REV r 10/82 10/82 500 7 -.. �''4�26 �