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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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 herein described. This application is Trade 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 j Local Health District. Job Address -.-. �j '� ,SiO��- A_!tE__ – City ' AQP Lot Size PM Owner's Name. 11,61 (,44/121 44'10 Address 93'7 /4&177Ao.--tlE Pg I�!oDGa Phone Contractor FL4VV LJ�a-j Address 7 At. DE4ldE�� License No.[}Z�Y7A Phone 6 - 97 i TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPA ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK = - ----SEW.ER-LINES— —.DISP_OSAL-ELD_. PROP. LINE FOUNDATION AGRICULTUR ELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T y Type of Casing Specifications F) Public n Other Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Dep l I Eastern Surface Seal Installed by Repair Work none 171Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter =7.---- Sealing '1 Sealing Material Itop 50 Depth r Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION'I I AREPAIR/ADDITION i 1 DESTRUCTION 11 (No septic system permitted if public sewer is S f "`` ' available within 200 feet.) Installation will serve: Residence Commercial Other f}� 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. ❑ w Method of Disposal Distance to nearest:. Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation! Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation"f Property Line DISPOSAL PONDS ❑ V 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-issuedwl-shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. Signed Date: R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: % r. r, are'-' c ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca,,823-7104 O=Tracy 835f6385 _ r+ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O:`Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH1 -24iREV.tiHsl EH 144-28