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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .It (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 Rules and Regulations of the San Joaquin Local Health District. s 'l Job Address 30 1 Al, 40 Z_C) City Lot Size PM I Owner's Name Azej llml r_L::�[�J� ess 4c:�, Phone Contractor S Cil`�Address d CHILI icense No. ' 3 Phone 1��5►!ao TYPE OF WELL/PUMP- 1" ,'NJ NEW WELL EJWELL REPLACEMENT ED DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' X SEWER LINES DISPOSAL FLD. PROP. LINE FOU DATI 1 `.-P AGRICULTURE WELL OTHER WELL PITS!/SUMPSr i INTENDED USE TYPE OF WELL-, P LEM AREA"'"CONSTRUCTION SPECIFICATIONS � ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private :0 Gravel Pack ❑ Tracy of Casing Specificatians ❑ Public ❑ Other - ❑ Delta Depth o Seal Type of Grout ❑ Irrigation �pprpx. Depth ❑ Eastern Surface Seal�lnstalle Repair Work Done ❑ Type ype I Pump __ , P`,� _ State Work Do Well Destruction ❑ Well Diameter Sealing Material (top 501 Dept ( Filler Material (Below 501 1 TYPE OF SEPTIC WORK; iNEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 4�(, Commercial_ Other Number of living units: Number of bedrooms __,_ 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 Property Line r. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEDDistance to nearest:-''"'"Well Foundation = """`—Prope-rty Line'"" "— ` SEEPAGE PITS ❑ Depth Size Number SUMPS .❑ Distance to nearest: Well Property Line DISPOSAL PONDS ❑ 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signedr Title: Date: FOR DEPARTMENT USE ONLY r Application Accepted by � Date Area Pit or Grout Inspection by Date Final Inspection by 21 pie Additional Comments: r(1'L! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 1 DATE PERMIT'NO. r EH 13-24 IREV.t/y slur EH 1428 J '-1