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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 (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, Job Address G l-oy-0;, Re/. City Lot Size PM Owner's Name Vice Pow 04L � Gtav�7 Act Address Phone Contractor ))7V?7)-P W -'wN Address 471P;k" LrrG /4��• License Na Y�99` Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REAL4CEIVIEhIT 3 l ti3 DESTRUCTION LJ i .� .. ... _� -.. ._. .�.U.RtIP IINSTA_�LAJION�4._w;.._ �_. SYSTEM Rj:P.AIR•.[ - .W . . __ OTLER_.Q_- 1 ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j r. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ED Open Bottom Q Manteca Dia- of Well Excavation Dia- of Well Casing ! I, ❑ Domestic/Private"6CC�_Grav€f'Pa'ck ❑"Trac`y —"Typ"e of-C tiSgJ" + Specifications f'I Public tither Cl Delta Depth of Grout Seal Type of Grout Irrigation i'A� ov. i I Irri { r } g � Depth 1 1 Eastern Surface Seal Installed by Repair Work Done LJ State Work Done Well Destruction ❑ Well Diameter 1 S�alinggMaterialtop 50') ) I € Depth ? Filler Material (Below 50') _ O TYPE OF SEPTIC WORK: NEW INSTALLATION (Cl REPAIR/ADDITION}/! DESTRUCTION I I {No septic system permitted it public sewer is i I available_within 200 feet.) } g Installation will serve: Residence p Commercial_ Other """�"""`--""�-�r�E f� 1 I Number of living units: J.-._._ Number of bedrooms J zr i Character of soil to a depth of 3 feet:----�--.- ' Watet table depth 8` SEPTIC TANK J�T Type/Mfg CVs RV-4, Capacity I c�O No'Compartments } ! PKG. TREATMENT PLT. ❑ LT1 `' Method of Disposal --�� 1-;-n— Distance i } i +r 7 ---- i mss ..._. -. . Distance'to nearest: Well y Foutrdatio ` o P, Party Line lye` LEACHING LINE I No. & Length of lines `�'� ` " ) { x CO 3_ Total length/size.g � FILTER BED El Distance to",nearest: Well ` Foundatiori�u«` Property Line F71111 } Y SEEPAGE PITS t k`}- -f) p@f1 �+. Size ;r Number] L7' �U � { I SUMPS istance`t"o nearest: Well Foundation Pro e Line { DISPOSAL PONDS �```��`�i! `c ��f � PrtY { � -- I I hereby certify that I have prWr C hist' pPP'Ation and that the work will be done in accordance with San Joaquin ct unty ordinances, state laws, ar dy I rules and regulations of the San Joaquin Local Health Di$trict. } 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 7 employ any person in such manner as to becor' a subject to workman's compensation laws of California."Contiactor's hiring or sub contracting signatufe certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- t tion laws of California." ' Z The applicant must call for all required inspections. Complete drawing on reverse side. �J Ell Signed X ! Title: Data: IV IJ-NY E i OR DEPARTMENT USE ONLY fApplication Accepted by 2 Date /o f Area 2-16 } Pit or Grout Inspection by Date /U I I Final Inspection by Date /3 Jf 19 ' Additional Comments: `r i 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 j� Applicant- Rat u n alcopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 35201 FLEE t. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ��77 rr'�� (� r . EH 13-24{REV.l i M 51 v �tO�'SCS'ar. EH 14-28