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YL � � '�901. fq,� Ten-terve- &gmplel7 an da* APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 SPIN !'� ��41�J LOCA. DATE ISSUED EXPIRES 1 YEAR FROM DATE ISSUED HEAL-fH DISTRI�-T PERMIT (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 Joaquir County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address 1A _ Subdivision Name Owner's Name C'Jsp'i s M 11 Address ;Z©14/ E; WeLln Phone Contractor's Name Puryianee Drillers Drilling Corp.License No. 377 q z 3 Phone W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial Open Bottom ❑Manteca Dia. of Well Excavation —A-1— 9! Domestic/Private Gravel Pack Tracy Dia. of Well Casing Publ i cOther Del to 1410- �-1 � Type of Casing J .G'� 4tAZfv j Irrigation Approx. E] Eastern Cathodic Protection Depth Specifications Depth of Grout seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 5C1} Depth Filler Material (Below 50') Cb TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is P available within 200 feet.) Installation will serve: Residence r. Commercial Other Number of living units: Number of bedrooms Lot size R1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Fj Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line w SEEPAGE PITS ❑ Depth Size Number 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 workmanb 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 issue I shall employ persons subject to workman's compensation'laws of California." The applic us c 1 for all required inspections. Complete drawin on reverse side. Date: Signed X Title: �-3p—sP3 T USE ONLY Appli ation Accepted by FOR DEPRRTM Area ('j �. [ Stk 466-6781 Additional Comments: U Lodi 369-3621 Pit or Grout Inspection by bate Manteca 823-7104 Final Inspection by —j f:,- i Date U'I.�� ❑ Tracy 835-6385 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 PERMIT NO. INFO �e �{ B 7-3-/Y 7 EH 13-24 REV. 10/82 10/82 500 14-26 r