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APPLICATION FOR PERMIT '�"'4 SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 46&--QM- PERMIT � PERMIT EXPIRES 1 YEAR FROM"DA6TE ISSUED_ (Complete in Triplicate) �2_f4 — '20 -t c j 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 Hcgulations of the San Joaquin Local Health District. Job Address ULA ruLas City Lot Size PM O +lr P1 1 Address � e�- Own Name Q rq� ^ Te Pham /4�7 _ ContractorAddress!l�SJ��+�'��m � ___—License No. TYPE OF WELL/PUMP: NEW WELL . WELL REPLACEMENT 1.1 DESTRUCTION IJ J — PUMP INSTALLATION ❑ SYSTEM REPAIR REP IIR L) OTHER DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES31L._J.-f1 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS -- t _ - - I INTENDED USE -TYPE OF WELL T PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ � 1_1 Industrial 1-7 Open Bottom C7 Manteca Dia. of Well Excavatio J Dia. of Well Casing 1 , ❑ Domestic/Private (1 Gravel Pack 1-1 Tracy Type of Casirig I "C- Specifications / f ('! Public 17 Other � 1-1 Delta Depth of Grout Seal -�?'-lam_-__ Type of Grout I I If _- Approx. Depth I I Eastern Surface Seal Installed by—_-- Repair y --Repair Work Done 1.1 Type of Pump I 1{,p, _ � State Work Done - I Well Destruction 11 Well Diameter 1 2— Sealing Material (top 501 Depth __ Filler Material IBolow 50') - --- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESIRUCTION I 1 1No suptic system peunitled if public sewer is f available within 2011 feet.) { 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 i_I Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. 0 tI Method of Disposal _ ) Distance to nearest Well Foundation __ - Property Line LEACHING LINE L1 No. & Length of lines - Total length/size --...- I FILTER BED � I-I Distance to nearest: Well __-._._.__ Foundation _-___._-_._._____. Property tine _______._-._. � SEEPAGE PITS I I Depth -- I Size _�._�_ -----------._. Number SUMPS l'I Distance to nearest: Well __- Foundation-._.. _- Property Line DISPOSAL PONDS Cl 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.1 shall employ persons subject to workrnan's compensa- i tion laws of California." The applic must c for all requir d inspections. Complete drawing on reverse side. Signed Title: Data: ,t;Q.ILt.�.ft �itsvu Ue40R PART E USE ONLY Application Accepted by Date //.5-�/ a Pit or Grout Inspection byDate 3- �/ Final Inspection by Date Additional Comments: - O Stk 466-6791 ❑ Lodi 369-3621 V 0 Manteca 823-7104 0 Tracy 1335-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 CK 9 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. rINFO EH02AIREV.,i'n5i Ll 11 /✓-/ rC./rk/! } [ fi fH[4-29