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t r l h APPLICATION FOR PERMIT n, SAN 1JOAQUIN LOCAL HEALTH DISTRICT 1601 E. }-HAZEL T ON AVE., STOCKTON, CA Telephone Q09) 466-6781 A PERMIT EXPIRES TYEAR FROM DATE ISSUED y ;I (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 the Rlati$$$$9�UPI Joaquin Local Health District. r lit U .2 miles north of Hwy 26 Job Address 720' west. of- Wall Rd. CityLinden Lot Size PM' ?i Owner's Name Elizabeth Read Address 5725 Wall Rd. ,Li.nden Phone 7 Contractor Purvzance Drillerad4ace P.O.Box 64,L.i.nden License No377923 Phone 857-'3554 TYPE.OF-WELL/PUMP: NEW WELL it WELL REPLACEMENT LJ DESTRUCTION ❑ C PUMP INSTALLATION $0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION 1° AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i. F- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS ❑ Industrial X Open Bottom ❑;Manteca Dia- of Well Excavation .Dia. of Well Casing 12 3/4 ❑ Domestic/Private ❑ Gravel Pack ❑Jracy Type of Casing Steel Specifications x 0188 Wal t M Pubfic n Other ❑:pelta Depth of Grout Seal 0 Type of Grout X Irrigation .. Approx. Depth J I iEastern. Surface Seal Installed by _ Repair Work'.Done ❑ Type,of,Pump H.P. 40 State Work Done PeAO Well Destruction E) Well Diameter i Sealing Material (top 50') DepthFiller Material (Below 501 F TYPE OF SEPTIC WORK: NEW INSTALLATION II. REPAIR'/ADDITION I DESTRUCTION I1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other t Number of living units;_ Number-of bedr_oams Character of soil to a depth of 3 feet: fi Water table depth SEPTIC TANK ❑ Type/Mfg ''Capacity No. Compartments PKG. TREATMENT PLT. D7 Method of Disposal Distance to nearest: Well i '.Foundation Property Line LEACHING,LINE �❑ No. & Length of lines' 1 Total length/size F FILTER-BED -_,❑ Distance to nearest !i Well 7 Foundation- Property Line i SEEPAGE PITS f I Depth L; Size Number SUMPS - L Distance to riearest: Well Found'a'tion Property Line + DISPOSAL PONDS ❑ F 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 s rules and regulations of the San Joaquin:Local Health District. F Home owner or licensed agents signature ct3.tifiesthe following: "I certify that°n the performance of the work for which this permit is issued, I shall not ' employ any person in such mannerl'as to hecome subject to workman's compensaticiA lsws'of California." Contractors hiring or sub-contracting signature certifies the following I certify that rnihe performance of the work for which this pq,r4 tit is-issued;l shall employ persons subject to workman's compensa- tion fawsof California , The applic us t cah i t� lttied:inspections. Clomplete drawing on revs a side. Signed X Title:- .Pres. ent Date: 6/2/88 i n- F DEPARTMENhUSE ONLY r Application Accepted by a t^^ f Date��-1p `�� Area 2-- Pit or Grout Inspection,by Date + al Inspection byDate_11 x.14 Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca,823 7104 ❑ Tracy 83 i! ' Applicant Return all copies to: Environmental Health Permit7&vices 1601 E. Hai efton Ave., P.Q. Btlx 2009, Stk CA,95201 o iib �. . FEE 1NF0 AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY PATE PERMIT NO. ! + EH1 -21fNEV.t/rsSY }� S��v ��•» ° ,"lJ ��(-ISG — ' ' EH 14-29 - iI