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' - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r ' 1601 E. HAZE 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. ' Job Address -imlle East Of Fine Rd. mi1e Nart}a;t�f Flood 14n PM Owner's Name Mel. Berg Address 19270 E• Comstock Rd. Phone Contractor Purviance Drillers Drilling Corp. Address P. 0 O Liicense Nn.377973 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER YI repair w1l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL, FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL •WELL. PITS/SUMPS INTEND D SE_-) TYPE OF WELL PROBLEM AREA—,,_CONSTRUCTION SPECIFICATIONS ❑ Industrial pf Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing7WI 4111A /be'/211/944, Specifications t'l Public I Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done X Type of Pump '11 Z H.P., State Work Done _ Well Destruction ❑ Well Diameter 151 rSealing Material Itop 50'1 Depth 360 Fr Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION f I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.l t 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ,.�SUMP-S.,_ - _ Ll 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."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 compensa- tion laws of California." The_applicant must call far all a fired inspections. Complete drawing on reverse side. signed X Title: President Date: 12/10/87 tQ FO R ARTMENT USE ONLY Application Accepted by Date Area i J��yy 2 Pit or Grout Inspection by Date Final Inspection by Datq��u � 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.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE pp PERMIT-NO. dal -M EH 13-241REV.1/1151 g �� I--Z�-6t-1{ EH 14-29 11