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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application ,s 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 Distri t. �' ►y.�'' Job Address City .�E q�ii f.t� Lot SizJOO X 163 PM Owner's Nar,lester & Roberta RaineAdress3 Shasta Dr. Rio Vista Ca. Phone707` 374 605 Contractor Self Address Same License No. Phone Same TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPINSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Industrial ❑ Open Bottom Ci Manteca Ria. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private Ll Gravel Pack ❑, Tracy Type of Casing— Specifications P Public l.] Other 1-1 Delta Depth of Grout Seal Type of Grout I I irrigation Approx. Depth ( i Eastern Surface Seal Installed by _ Repair Work Done 11 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION " ' REPAIH/ADDITION : I DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.I installation will serve: Residence T 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 t la Capacity �"% No. Compartments PKG. TREATMENT PLT. L] f + _ Method of Disposal_7 f �tip/sal � Distance to nearest: Well _ Foundation Property Line LEACHING LINE No. & Length of lines ' Total length/size [ __ FILTER BED Ll Distance to nearest: Well fish Foundation Property Line " e SEEPAGE PITS ^ Depth „Size _ Number SUMPS LI Distance to nearest: Well vu o' Foundation _� l Property Line DISPOSAL PONDS ❑ v� I 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 taws 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." The applicant mu 'ail for all requiredinspect' ns. Complete drawing on reverse side. Signed X t Title: Date. FOR DEPARTMENT USE ONLY Application Accepted by /� •"�`fit' i�f^� Date Area C •'1 s it r Grout Inspection by. Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. 7H� G� . EH 13-24IREV.1!85i EH 1428 ((ff