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APPLicATION FOR PERhiiT SAN JOAQLi'� LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. `� V Telephone (209) 466-6781 DATE ISSUED o2 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (Complete in Triplicate) ll the work herein Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insta described. This application -is madejjin 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 �r°° Subdivision Name one Owner's Name _ - PSS G Lim Address '7� �05� �T' M- Ph Phone Contractor's Name License No. 7 TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION ❑ r f PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER l u PROP, LINE SEWER LINES DISPOSAL FLO. „ DISTANCE TO NEAREST: SEPTIC TANK _=--^--~=- �"" ~'- PITS/SUMPS FOUNDATION AGRICULTURE WELL __ OTHER WELL Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation LJ Domestic/Private Gravel Pack ❑Tracy Dia., of Well Casing_ . ❑ Public [j Other, ❑ Delta Eastern Approx. Type of Casing Irrigation ❑ Spec:ifications , Depth Depth 'of Grout Seal Cathodic Protection R Geophysical Type of Grout ❑other Surface Seal Installed by _ ' � Statfe-WorkTDone '�-•�~``^""'-''' 41 � Repair Work Done ❑ ,Type of PUMP'r- H P Well Destruction ❑ Wel I' Diameters• Sealing Material (top 50') e Depth - Filler Material (below 50')" sewer TYPE OFISEPTIC WORK: NEW!INSTALLATION ❑ REPAIR/ADDITION (Na 5eptic,tank or seepage pit avapermitted public �s ilablewithin200feet.) r � r Installation will serve. Residence Commercial Other fir. kt Number of -bedrooms Lat size' -^ . Number of living units:', „ !.R Wat re table depth Character of soil to a depth of 3 feet: y,,,;M y No. Compartments 7- atipacityp SEPTIC TANK � ~Type/Mfg s Y Method of Disposal wGapacity, - :—�, PKG. TREATMENT PLT. ❑ :Type/Mfg �- F'h rP.rop rty Line SEWAGE SYSTEM Distance to nearest: Well Foundation /�- - DESTRUCTION i s _ r'Total length/size D LEACHING LINE 1Noj ❑ € .:& Length of lines r 1 1 + Fourdatiw- - � O/ Property Line' E FILTER BED :Distance to nearest: Welles C�3_ Depth ` " Size Number �d SEEPAGE PITS Foundation Property Line,__�_�._ SUMPS i LIDistance to nearest W""Well _ I a a DISPOSAL PONDS `'N`" i _ rAr I hereby certi•fy�-thatSI?h4X'erulesaand regulaptponsaof�tfie-SanjJ thinwork iHealthdDnstricte in ecordance with San Joaquin county ordinantes, state ll law r in Local that in the performance the work for which this Hpme ownei` 67 licensed"a`gent's siyndtur certifies the manne na Y permit is issued, I'shall not employ any person insuch,manner as to becomeIscertif tthatrinathecpePformance of6nsatiorwthefwork�fornwhich or sub-contractin signature ce tifies the follo„Ing: Y Contractor's hiring, 9 this perm•i.t:is issued, I shall employ .p�sons subject.to�workmanus;compensation laws of Calitfornia. •,„ The applicant-must call r alll eq d inspections, Campleteldr"k, on}re� reverse�side• 4 ” S Date: ,: y ,s Title: lvt��vv Stgned tX 3€. "'` 'FOR DEPARTMENT USE ONLY � ,Stk 466-67$1 ' k Area Applicaiionn Accepted by -�-Q: r ❑ Lodi 369-3621 k Additional Comments-— 4 Manteca 823-7104 i - f7 _ Date , Pit o<Grout=Inspection•Oy'�_ """' �" Tracy 835-6385 y Date D Final"In petition by �- t Applicant - Reurnall copies to: Environmental Health Permit/Services�1601 E. Haz lton Ave., P_0. Bo'x 2009, Stk., CA v95201 RECEIVED BY GATE PERMIT NO. FEE BASE. AMOUNT DUE AMOUNT REMITTED i � INFO ., y, �' r�, C t- �S.r':� t .��s_ b� o� T ( O -,+.•,.,,,,,,.,__,,.�.. ":-�... ....,. � 10/82 500 EH'13-24 REV. 10/82 14-2.6