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X APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F 1641 E. HAZEL T ON AVE., STOCKTON, CA Telephone (249) 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. 1852 for.well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 10 RO G�` l�f ..,_ City Lot Size ! PM �7 Owner's Name . 1'S/adro few Address �!'3��! 41 Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR TIC TANK SEWER LINES DISPOSAL FLD. OP. LINE,-- 0 INE FOUNDA I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROB CONSTRUCTION SP TIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o avatibri Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy a of Casino Specifications ❑ Public ❑ Other - ❑ D Depth of Grout Seal Type of Grout ❑ Irrigation _-4p r ❑ Eastern Surface Seal Installed by Repair Work Do ype of Pump H.P. State Work Done estruction ❑ Well Diameter Sealing Material (top 501 ` Depth t Filler Materia! (Below 501 - ~ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION ❑ ,DESTRUC N fN . septic system permitted'if public sewer is ;1 a liable within 200 feet. Installation will serve: Residence�I" Commercial Other " �'" i 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 y PKG. TREATMENT PLT. ❑ A- 1 Method of Disposal JI Distancetonearest: Well Foundation i Property Line LEACHING LINE ❑ No. & Length of lines ` Total length/size r= - FILTER BED ❑ Distance;to nearest: Well.# Foundation Property'Lineaf i ff , SEEPAGE PITS ❑ Depth 'I -Size' Number i� SUMPS ❑ Distance to nearest, Well Foundation Property Line # f 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: "l certify that in the performance of the work for which this permit is issued, /-shall not employ any person in such manner as to lbecome 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, I shall employ persons subject to workman's compensa- tion laws of California." I J The applicant must call for all r quired inspections. Complete drawing on reverse side. � d 9 Signed X "' Title: Date: R DEPART NT USE ONLY Application Accepted by �" Date _�/ Area Pit or Grout Inspection by l�t Date Final Inspection Gate Additional Comments: ! '74 �I ❑ Stk 466-6781 ❑ Lodi 369-3611 ❑ Manteca 823-7104 ❑ Tracy 83 Applicant- Return all copies to: Environ mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE 1 AMOUNT REMITTED GK RECEIVED BY DATE PERMIT'N0. i + EH13M28 24/REV.5/B 51 /9' '9—: EH 1 i I