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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 Triplicate) Application h 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.1882 for well/pump and the Rules and Regulations of the San Joaquin CF , Local Health District. po.eC Y7 Job Address �I X7_"0 X1.11' l/ri' `L`g�VE-�`V ] city Lot Eula�� aCCZ� PM OwneY, 6�Name �''�NISLI�?.f 'Address 11�'7�p-�1 8 Kilka ap— .( Phone W Contra or's Name �.,��T---- License No. � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.❑- DESTKUCTON ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK' '-SEWER'LINES _. "`DISPOSAL FLU" PROP.LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CIIndusvial { ❑ Open Rpttom ❑ Manteca Dla.of Well Excavation Dia. of Well Casing El Domestic/Private i 11 _Gravel Pack ❑Tracy- •• Type of Casing Specifications ❑ Public I ❑ Other O Delta Depth of Grout Seal Type of Grout ❑Irrigation f ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.p. State Work Done ' _ I Well Destruction ❑ Well Diameter Sealing Material(top 50') Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEIN INSTALIATfON "REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .� eveliable within 200 feet.) , Installation will serve: 'Residence_ Commercial Other Number of living unite:-1— Number of badrj omss. Character of soil to a depth of 3 teat; Water table depth SEPTIC TANK. Sid Type/Mfg / Capacity -O � No, Comparonents PKG.TREATMENT PLT.❑ ne. .._-.... Method of Disposal . � I Distance to arest:_ Well.,f531J1-1 Foundetwn _J.�- Property Lie6- - LEACHING LINE ElNo: i Length,of fine 'Totallength/size s `t °•—•' - FILTER BED Distance to nearer:..... We112060 a Foundation '3�z Property Line , SEEPAGE PITS ❑ Depth - Size Number - SUMPS ❑ Distance to nearest: Well Foundation Property Lim ` DISPOSAL PONDS ❑ hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, an, rules and regulations of the-Sen Joaquin Local Health District. Home owner or licensed agents 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 n,anmr as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracdng signature i certHtes the following:"I certify that in the par omnanca of the work forwhich this pemdt is issued,I shell employ parsons subject to workmen's compense- tion laws of California," I The spell t must II for all requir ' spactions. Co to drawing on reverse side. Tl� ( Signed Title ii �t�s,�2 Date: �G17 ( F R DEPARTMENT USE ONLY Application Accepted by• Date Area__-_ _ Ph or Grout Inspection by Date Pinel Inspection by Date 3 Additional Comments: >: XStk 458-8781 ❑ Lodi 3W-3621 O Manteca 823-7104 ❑Tracy 83SON /Applicant- Return all copies to: Environmental Health Permit/Servicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 • FEE UNT DUE AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT"N0. INFO 4 EN13-24 IREV.to/SII aR„�