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„4r APPLICATION FOR PERMIT ,_ji SAN JOAQUIN LOCAL HEALTH DISTRICT u 1601 E. HAZE i ON AVE., STOCKTON, CA t.. Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) W t. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. his 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. - Job Address City Lot Size PM Owner's Name 1�, Addressi _-� Phong �j I Contractok f Address y icense`rilal�Pholyd � ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q PUMP INSTALLATION El SYSTEM REPAIR ❑ a OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PIT5/SUMPS _ .--,.,INTENDED USE TYPE OF WELL PROBLEMCONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom teca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications (71 Public Cl�Oth n Delta Depth of Grout Seal Type of Grout _ i /:Irrigation ..Approx. Depth I I Eastern Surface Seal installed by Repa�Destrbn Type of Pump H.P: -State Work Done F WV ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50'1 l TYPE OF SEPTIC.,WOAK: - NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) rn Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms .tCharacter of sail to a depth of 3 feet: Water table depth 'SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal S Distance to nearest: Well Foundation Property Line \/ LEACHING LINE D. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number n SUMPS�r” *-v x r Cl Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ I hereby certify that/ have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulation3 of the San Joaquin Local Health District. I 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,." � I The applica ust tail for ail required i c'ons. omplete drawing on eg a side.: l Signe - Title: Date: + 4 FOR DEPARTMENT USE ONLY r ' Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date {J Additional Comments: s .(r Stk.-,.466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 '-_ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2W9, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED CKA [3Y DATE PERMIT NO. di +.EH 13-24 Wv.r l H sr EH 14-26 1 '