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APPLICATION FOR PERMIT f � SAN JOAQUIN LOCAL HEALTH DISTRICT �3—-�Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �•j' �/P Telephone (209) 466-6781 DATE ISSUED 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 madefin 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. Job Address 9645 Leland subdivision Name Owner's Name Mrs Bill pullum Address 1078 Bristol Phone 465-92B4 i Contractor's Name Clerk Well, & Egl3ipLicense No. 371560 Phone 462-5597 TYPE OF WELL/PUMP WORK: NEW WF� f3 WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM'REPAIR, OTHER DISTANCE TO NEAREST: SEPTIC TANK ++_i B 0 s SEWER LINES DISPOSAL FLO. PROP. LINE 10 t od FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS a O INTENDED USE TYPE OFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation 1 B 5/8" 1 ;D Domestic/Private >(N)Gravel Pack Tracy Dia, of Well Casing 6 _5Z8 1} Public Other' . Delta Type of Casing 1 2 Steel L Irrigation Approx. Eastern Specifications 71Depth �Cathodic Protection Depth of Grout Seal 6 D t SSS ❑Geophysical K 1 Type of Grout U Other Surface Seal Installed by _ Clark H.P. State Work Done i t a l l Repair Work,Done ❑ Type of Pump LL{�1__Y,___ 1� Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth i Filler Material (Below 501) TYPE OF SEPTIC.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is i# available within 200 feet.) 1 Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size t F " Water table depth t� y Character of soil. to a depth of 3 feet: p SEPTIC TANK ❑ Type/Mfg'� Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg, Capacity Method of Disposal SEWAGE SYSTEM Distance'to nearest: Well Foundation Property Line F DESTRUCTION 1 LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation, Property,Line SEEPAGE PITS [ j Depth i Size 'Number SUMPS L Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s �� Y' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county t 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." The applica ,t iu9t call for 1 r15:51, ui d inspections. Complete'drawing on reverse side. Signed X . Title: Date: F EPARTMENT USE ONLY f Application Accepted by f Area Stk 466-6781 Additional Comments: .%* ti E] Lodi 369-3621 Pit or Grout Inspection by•' to Manteca 823-7104 Final Inspection by J D to ❑ Tracy 835-6385 v Applicant - Return all co i o: .{ Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i1 FEE BASE :AMOUNT DUE AMOUNT REMITTED RECEIVED BYjDATE PERMIT NO_ INFO EH 13-24 REV. 10/82 10/82 500;�.{ 14-26 7 1�