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APPLICATION r`0',i PERMIT ., SAN ,IOAQUit! LOCAL HEALTH ,]STRICT l 1601 E. HAZELTON .AVE., STOCKTON, CA PERMIT NO. - l� Telephone (209) 466-6781 I DATE ISSUED (p( W3 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED. �� 1 (Complete in Triplicate) . 1 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 the Rules and Regulations of the,San Joaquin Local Health District. µ Job Address �� _ Subdivision Name Owner's Name i si JQ�l17t,eflw Address ? !'rr / Phone Contractor's Name Puryianee Drillers Drilling CernLicense No. -- Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WE��LLfI,�R. PLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION ❑ X;y REPAIR WOTHER ❑ �� DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE W FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL '-PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial `' .❑ m Open Bottom- ❑ Manteca M .'T Dia.-of .Well-Excavation ❑. ,r- i T Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing ix Irrigation Approx. ❑ Eastern Depth Specifications ;i i ❑Cathodic Protection Depth of Grout Seal !< ❑Geophysical Type of Grout Other Surface Seal Installed by E Repair Work Done ❑ Type of Pump bkfd. H.P. 2. State Work Done Well Destruction ❑ Wel-1 Diameter Sealing Material (top 501) ` Depth Filler Material (Below 50') —F F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 9 e available within 20O,feet.) II Installation will serve: Residence _ Commercial Other _J Number of living units: Number of bedrooms Lot size r Character of soil t6_A depth of 3 feet: Water table depth l I' SEPTIC TANK ❑ 0 Type/Mfg Capacity No. Compartments s 1 PKG. TREATMENT PLT. ❑� Type/Mfg / Capacity Method of Disposal ; SEWAGE SYSTEM 4 Distance to nearest: Well . 'f' Foundation Property Line ,4 e DESTRUCTION LEACHING LINE ❑ —No. -& Cength of lines _Totallength/size FILTER BED ❑ Distance to nearest: Well ;Foundation Property Line i SEEPAGE' PITS' ❑ _Depth..._-- � �r - Size '� - �Number w SUMPS ❑ Distance;to'-nearest: Well - Foundation-, _r Property-Li-ne. DISPOSAL PONDS ❑I !j have prepared pp I hereby certify that I h re ared this application and that the work will be done in accordance with San Joaquin county u ' ordinances, state laws, and rules and regulations of the. District.-San Joaquin Local Health is , F Home owner or licensed agent's signature certifies the following: "I certify that iri the performance of the work for which this "I permit 1s 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 to1workman's compensation laws of California." The appliedc t r a must call forequired inspections. Complete dra ing on reverse side. }( SignK YJ7 Title: (ee Date: ' F R DEP MENT USE ONLY Application Accepted by Area ❑ Stk 4fi6-6781 Additional Comments: Lodi 369-3621 Pit or Grout InspectiAto,.: Date Manteca 823-7104 U ' 'r Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copieEnviro menta`]` ealth Permit/Services 160 E. Haz lton Ave., P.O. Box 2009, Stk., CA 95201 i r EE BASE AMOUNT DUEWAMDUNTTMITTED RECEIVED BY DATE ;ERMIT qNO, c j NFO �3 �� D '� 4 EH 13-24 REV. 10/82 10/82 500 14-26