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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 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 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 Distric t. /�. Job Address _/ 7'c� / / 'AP-LA 1u A_- - City 4A HAaUpLot Size O s QPM Owner's Name A Address rs V^�` 1_.`,OEzls kE ' 4,#; rPhone r L,rsf^ Contractor SG'F _Address�"��^' ' _ License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout -_-, �^ I I Irrigation :—.-Approx. Depth I I Eastern Surface Seal Installed by - [\ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i I DESTRUCTION INo septic system permitted if public sewer is C1 available within 200 feet.) OJl Installation will serve: Residence Lf�_ Commercial_ Other Number of living units: -A— Number of bedrooms p- f Character of sail to a depth of 3 feet: p P AA4 Water table depth J Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property L'ne N D D S Tl C � An/I� v- Co AJ 11lA c ! TV c WS U c�'r=�wgx /-IN LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 appiica ust c 11 for ail r uired inspe ons. Complete drawing on reverse side. Q Signed X_. TitEe: w N r __ Date: /��_2L - I FOR DEPARTMENT USE ONLY Application Accepted by Date {dr D Area ` r Pit or Grout Inspection by / Date Final Inspection by Date tf Additional Comments: /r - - ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 i ❑ Tracy 835-6385 Applicant - Return allca es to: E:;�'�imenta!,�4ealth Per it/Service 1601 E. Hazelt Ave., P.O. Box 2009, Stk., CA 9 01 i FE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE ER NO. IN 0 CASH +.EH 13-241REV. EH 14-26 JJJ f ♦�