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APPLICATION FOR PERMIT \ SAN JOAQUIN LOCAL HEALTH DISTRICT 1901 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 4968781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work harm daacnibed This appi "mr is made in cprgillatce with San Joaquin County Ordina os No.bib for sewage or No.1962 for wei/puny wW tlw Ruin and Rapulalions d the Sat Joaquin Local Health District. ,� Job Address gq sv �- �/cf�/ *� �-P 4 ,(J /��T336 city /�n��a"Lot Size PM Owner's Name l,� ►/'y 0? fa E/t c-Q_ Addr. rO� F4Km ag — Contractor /waA0j h /I Address 3 dY' S Ali License No.3212il- Phone "79 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES DISPOSAL FLD. PROP.UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PRO13LEM AREA CONSTRUCTION SPECIFICATIONS'/ ❑ Industrial ❑ Open Bottom Fv _y Die.of VZ Excavet s Dia.of Wei [71Domestic/Private �Gravrl Pack /❑Tracy Type of L': Public ❑ Other O Deka Depth of Grout Sed Type of Grout rigstion pv r��+' gr�►pagx. Depth O EUM, Surface Sed Installed by Repair Work Done C3 Type of Perp H.P. Stall Work Done Well Destruction O WON Dunne Sawing MaterW Itop 60'1 Depth Filler Material(Below 10) TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADOITION❑ DESTRUCTION 0 (No septic system permitted If pubic sewer is syllable within 20 feet.) Installation will serve: ROOidertce_ Commercial_ Other Number of wing units: Number of bedrooms N Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compatmrnn PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation_ lProPwtY Line_ LEACHING LINE O No.8 Length of limes Total length/size FILTER BED O Distance to nearest: Well Foundation Property Lire SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to neerrct: Well Foundation Property Line DISPOSAL PONDS L 1 hereby cwtlfy that I have prepared this application and that the work will be done In accordance with San Joaquin c,:unty ordinances,star laws,and rules and regulstlors of the San Joaquin Local I I"hh District. Homo owner or k etsrd agent's signature oertMles the foiov*V:"I certify that In the performance of the work for which this permit is band. I shall not employ any person M such mama as to become subject to workmen's compersation laws of California."Contractor's hiring or sub-contracting algnaturr certlfss the fo f*Ning:"I certify that In the performance M the work for which this permit lel ri,1 shalt employ persons subOM to workman's compensa- tion laws of California." The applicant fall for u tions. Complen drawing on terse- sleds. !V fll.(�l Date: Signed �� This: —r— �4)71 DE�ARTINENT USE ONLY � y 4 7 Area /3 Application Aecrptwi by // — Pit or Grout Inspection by s+' Dan 6 – 1 `�;WW I.opecUon by •"/ �L Dan AV Additional Comments: r �^A / C' Stk 4W6761 4Lodi 60- 1 ❑ Manteca 823 7104 O Tracy SX-M ie6 ADpkont- Return all copies to: Envirownental HOekh Poo, A/Servioas 1001 E. Ha:Nton Ave.,P.O. Box 2000, Stk., CA 96201 FEE MOUNT DUE AMOUNT mirmiTTED r H RECEIVED By DATE ►Ef1MIT.N0.