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t ` Al APPLICATION FOR PERMIT SAN JOAO.UINK LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE'ISSUED F` (Complete in Triplicate) Application is hereby made to the San Joaquin Local 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. 1862 for well/pump and the Ryles and Regulations.of the San Joaquin Local Health District. J u Job Address .P s"�' rte•. I t-,�1`�121P "r city S IS N'.` Lot Size��C. ryPM l Owner's Name ISIR Address a 4 1 ,.-Li S 1"� ('a �' Phone ContractoriIJA%, Y Kris- 4, f"C: Address--P-O- License No. Phone (� f TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑F SYSTEM REPAIR ❑ OTHER ❑ DISTANCEIQ-NEAREST: SEPTIC TANK k SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.-o avat>'r1 F Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by 'Repair Work Done ❑ Type of Pump i H.P. State Work Done rt Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth R Filler Material (Below'50') TYPE OF SEPTIC WORK: NEW INSTALLATION I7 REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence— Commercial_ Other " ^ - Number of living units: Number of bedrooms -- -- -- _= 1•j'} Character of soil to a depth of 3 feet: `Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ° Method.of Disposal Distance to nearest: Well Foundation 1. 1^'. Property Line LEACHING LINE ❑ No. & Length of lines , _ h g � Total length/size Y//II FILTER BED ❑ Distance to nearest: WeII. -,Foundation t 'Property Line ` SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: 'Well Foundation Property_Line. DISPOSAL PONDS El t I hereby certify that I 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 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,-1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all required inspections. C mplete drawing on reverse side. Signed Title: 1,4- 3 "` ( t $7 Date: f FO EPARTME T USE ONLY e r Application Accepted by Date � � Area Pit or Grout Inspection b $ Pe Y Date �Final Inspection by Dat,3=2� 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63.85 t Applicant- Return-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O._Boz 2009,Stk7�CA 9520i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. INFO CASH +EH1 -24[REV.3/8514 EH 14-28 /