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I� APPLICATION FOR PE&':I7 i - {,g SAN JOAQUIN LOCAL HEALTH DISTRICT 2--703 1601 E HAZELTON AVE., STDCKFDN, CA PERMIT N0. Telephonlephone (209) 465-6731 DATE ISSUED a 3 y ' + PER.11T EXPIRES i YEAR FROM DATE ISSUED (Complete in !riplicate) h wt Application is hereby ,rade to the San Joaquin Local Health District for a permit to construct and/or,ins tali the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for yell/pump ` and the Rules and Regulations'of the San Joaquin Local Health District. I• Job Address �!N_ ,_ c r-r✓ / QI Subdivision Name — — - Owner's Name 2z..�QAfC -Ig1rAddress Sd22t ! Pham Contractor's Name _CWd eA- E, &W 071 —License No. ` ip Phone 5397/ x ; , :... � TYPE OF WELL/PUMP WORK: . NEW WELL EDWELL REPLACEMENT E] OES"RUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r r DISTANCE TO NEAREST: SEPTIC T.VIX SEWER LiNES w DISPOSAL FLD. I! PROP. LINE O ,; •...I;? FOUNDATION AGRICULTURE WELL OTHER WELL '` PITS/SUMPS f ,, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1' #} ❑ IndustrialJ Open Bottom []Manteca Dia, of Well Excavation ❑Domestic/Private 7 Gravel Pack ❑Tracy Dia. of Well Casing }` ❑Public ❑Other ❑Delta Type of Casing Irrigation Approx. r'IEastern ❑ r -- Specifications :Cathodic Protection — Depth Depth of Grout Seal IR {Tl Geophysical Type of Grout ❑Other Surface Seal Installed by i' Repair Work Done Type of Pump H,P, _— State Work Done r Well Destruction ❑ well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') _ j e pit.,permitted if public sewer is L 1 TYPE OF SEPTIC WOZK: NEW iNSTA(LATION LI REPAIR/AODIiiON {Na septic tank or seepag p p ____ available within 200 feet.} � Installation will serve: Pesidence Commercial X Other P-cv,`a S',p V-71'7 ! Number of living units: Number of bedrooms Lot size SQA L4--S v Character of so i6 to a depth of 3 feet: Water table depth - i ih SEPTIC TANK [� Type/Mfg Q i�dr70-- P oL G Capacity 1 1[7,40 No. Compartments — 1 f PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of.1Disposal 7f J �w til Distance to nearest: Well �, -J Foundation L U Property Lino 2.e7 t yj,4 II ..' N LEACHING LINE ❑ ito. & Length of lines Total length/size 4 FILTER BED [Er' Distance to neL,'est: Well _21M.-Af- Foundation' Property Line /O J 3 SEEPAGE PITS [j Depth Size Number y SUMPS L} Distance to nearest: Well _Foundation Property Line DISPOSAL PONDS �! �i I hereby certify that 1 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 werkmans compensation laws of California." + Contractor's hiring or sub-contracting signature certifies the following: "1 cert;fy that in the performance of the work for which ` this permit is issued, i shall employ persons subject to workman's compensation laws of California.".� 4 The applicant must call f r all requireG i pections. Complete drawing on reverse side. I Signed X Title: _f ot�r+„44 Date: DEPARTMENT USE ONLY I! '{ t4 Appiicition Accepted by _ Area Q Stk 466-6781 Additional Comments: —�_ Lodi 369-3621 Pit or Grout Inspection by Gate ❑ Manteca 823-7104 Final Inspection byDate C] Tracy 635-6385 Applicant - Return all copies :o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 20:,:. Stk., CA 95201 FCE. BASE �A11007, DUE AMOUNT REMITTED RECEIVE[: BY DATE II PERMIT NO. EH 1344 ?Lv. 10/° 1O/B7. 50D � 14:26 I r `