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APPLICATION FOR PERMIT , } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 15257 South State Route 99 Jab Address East Frontagg Road City Manteca Lot Size .40 Acres pM r Owner's Name Robert Lundbom Address 6225 Avenue A Phone 239-2995 Contractor's NameIT4;jj'No. No-6D5I Phone 847-0394 TYPE OF WELL/PUMP: NEW WELL X1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION (2SYSTEM REPAIR ❑ OTHER ❑ v` i DISTANCE TO NEAREST: SEPTIC TANK 100'+ SEWER LINES 1001+ DISPOSAL FLD. 100='bROP. LINE 30t FOUNDATION AGRICULTURE WELL None OTHER WELL 100'+PITS/SUMPS None GY INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 1 Dia. of Well Casing W Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5t--eel Specifications ❑ Public, ❑ Other C1 Delta Depth of Grout Seal 501 Type of Grout Bentonite i i ❑ Irrigation /�(�pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done .,❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial= Other' Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ •- Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of Was Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size - .- Number I SUMPS ❑. 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." Contractors 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 compensa- tion laws of California." The applicant 52Wxireatrl~or all required inspections. Complete dr wing on reverse side. Signed X� �� Title: "� A fjT� Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date "moi Area rt!�)Pit r Grout nspection by Da#e �� Firial Inspection by Date r Additional Comments: ❑ 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.O. Box 2009, Stk., CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH_ RECEIVED BY DATE PERMIT NO. + EH 13-24(AW.101831B•VY/AQF ¢ p • )q5io alt EH 4426 IIJJVV ✓ P 1