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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicates Application is hereby made to the San Joaquin Locai 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.1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address A, A'VlSim City Lot �'�' PM r Owner's Nan.e t Address !rV 27 ,L, Phone_ Contractor's Name License No. ��,. '`✓ Phone / TYPE OF WELL/PLIMP:. MEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LiNES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PiTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑industrial C7 Open Bottom ❑Manteca Dia.of Well ExcavationDia.of Well Casing ❑ Domestic:Private 17 Gravel Pack El Tracy Type of Cssing T Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout :❑ irrigation _,-,—Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done a Type of rump N.P._ State Work Done Well Destruction ❑ Well Diameter _ Sealing Material Itop 50') O Depth Filler Material(Below 50') (� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/Al)�D�(�IV DESTRUCTIOk LJ {No septic system permitted if public sewer is Q available within 2D0 feet.? Installation will servo: Residence Commercial_ Other Number of living units:—4— Number of bedrooms * Character of soil:o a depth of 3 feet: +/ / Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments y PKG. TREATMENT PLT.Q Ma!hod of Di sporps Distanre to nearest: Well Foundation _ Property Line LF_ACHING LINE ❑ i4o. & Length ER BED l Len th of lines rtr Total ie TDLstance to near9st. WellgF�ndation Property Z I Line �, v SEEPAGE PITS ❑ Depth w_;ize._ Number_ Q SUMPS ❑ Distance to n&eresl: Well _ Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county nrdinances,stets laws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the wor$fcr which this permit is issued,I shall not ernp:(ry any person in such manner as to become subject to workman's compensation laws of California."C6r:ractor's hiring or sub-contracting signature certifies the following:"I cert;fy that in the performance of the work fcr which this permit is issued,I shall emrloy persons subject to workman's compensa- tion laws of California." The applicant must call f "II d inspections. Complete drawing on reverse side, � Signed _ Title: Date: _ 57—.Z G� F FOR DEPARTMENT USE ONLY L Application Accepted by _ `t r' Dato_ Z U'J`r Aroa Pit or Grout Inspection by Data Final Inspection b l^-- Q Z U >1 Y G —�-� Data 4 f - Additional Comments: v� C Stk 466-&781 ❑ Lodi 369-3621 C,Menteca 823.7104 C-.Tracy 835.6385 Appficant• Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2", Stk., CA%201 INFOFEE AMOUNT DUE AMCU, REWTTED CA¢H RECEIVED By DATE PERMIT N0. • EH 71241REV 10;837 EH SFM tiZ (