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APPLICATION FOR PERMIT SAN JOAQJIN LOCAL HEALTH DISTRICT., 2703 x 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT 140. _�u� Telephone (209) 466-6781 �� r L�� AL DATE ISSUE 9��'"� PERMIT EXPIRES 1,-YEAR FROM DATE ISSUED �p !�3S l (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 made;in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and Regulations of the,,San Joaquin Local Health District. JobAddr�ule, Subdivision NameOwners Address [ap Phone Contractor's Name Purylance Drillers Dri ing CorpLicense No, phone TYPE OF WELL/PUMP WORK: NEW ,WELL LlWELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION } SYSTEM REPAIR ❑ OTHER, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE r. FOUNDATION ,1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE 6F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •� Yl� Industrial— Open Bottom ❑ Manteca Dia. of Well Excavation: l7V Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other' ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications Cathodic Protection ❑ Depth� Depth of Grout Seal ❑Geophysical ,t Type of Grout Other Surface Seal Installed by �! i� 3� State Work Done r d Repair Work Done ❑ Type of Pump "`5441. H.P. Well Destruction ❑ Well Diameter,l Sealing Material (top 501) — Sf DepthFiller Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: }Nf.umber of bedrooms Lot size w Character of soil to a depth of'3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal , SEWAGE SYSTEM ❑ Distance to nearest: . Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size 61 Property Line FILTER BED ❑ Distance.to nearest: 'Well Foundation P Y � SEEPAGE PITS ❑ Depth Size Number SUMPS �° Distance to nearest: Well Foundation.. Property,Line_ _ ��._:. DISPOSAL PONDS ❑V 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 'f this permit is issued, I 1 employ persons subject to workman's compensation laws of California," The applican must ca f all required inspections. Complete drawing on re rse side, x Signed X 'T Title: 1"L5� ent Date: 1 FOWARTMENT USE ONLY Area 2��3 ❑ Stk 466-6781 Application Accepted by r Lodi 369-3621 Additional Comments: ❑ Pit or Grout Inspection bye- Date Manteca 823-7104 Final Inspection by Date .��,A j ❑ Tracy 835-6385 Applicant - Return all copies to:1 En ironmental Health Permit/Services 1601 E, Hazelton Ave., P.D. Box 2009, Stk., ICA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. If INFO 10/82 500 EH 13-24 REV. 10/82 r 14-26 --