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APPLICATION FOR PERM;T 30, bSAN JOAQI:;"! LOCA! HcA.LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. _ h fff Telephone (209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE I5SUE0 DATE ISSUED (Complete in Triplicate) I Application is hereby made to the Ean 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 Joaquin Local Health District. Job Address ' l1' Subdivision Name Owner's Name Q $Q►� Address _ 21711 il'e. 413. fit, Phone Contractor's Name puryianee Drillers Drilling .Corp. License No. ?'q _ 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_.- Industrial OpenIBottom 0 Manteca Y Dia, of Well Excavation _ ter_V T Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public ,-4a irrigation E_1 Other Delta Type of Casing T .cx e[�.c- LX g Approx. _J Eastern Specifications !42 Cathodic Protection Depth Depth of Grout Seal (]Geophysical $Z U Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. .3 State Work Done well Destruction lJ Well Diametertt Sealing Material (top 50') _ Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (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: Number of bedrooms Lot size Character of soil to a depth of,3 feet: Water table depth Compartments m C SEPTIC TANK �j Type/Mfg.. Capacity No. C o p PKG. TREATMENT PLT. Type/Mfge' Capacity Method of Disposal - h i SEWAGE SYSTEM Distance'to nearest: Well Foundation Property Line DESTRUCTION Q t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance`to nearest: Well Foundation Property Line SEEPAGE PITS sE) Depth E Size Number SUMPSv Distance to nearest: Well Foundation Property Line DISPOSAL PONOS 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 workmant compensation laws of California." Contractor's hiring or sub-contrac-ting 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 applican mush ca 1 o al required inspections. Complete drawing on reverse sside. I` K Signed,X ` Title: 8140 SI CI _n. Date: I FOR USE ONLY �n_ _ T Application Ac c ted Area Stk 466-6781 f Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection byt -gky Date (] Manteca 823-7104 Final Inspection by DateQ Tracy 835-6385 it Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7 N0. INFO '�4 -7b _ l $$.os� 5•a p� C- — �f.y3S w EH 13-24 REV. 10/82 [1 q 10/82 500 14-26 1