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3., APPLICATION FOR PERMIT T�� �* }' SAN JOAQUIN LOCAL HEALTH DISTRICT ... 1601 E. HAZEL T ON AVE., STOCKTON, CA / Telephone (209) 466-6781 2 �G PERMIT EXPIRES TYEAR FROM DATE ISSUED * (Complete in Triplicate) r 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 Cb unty Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 'F Job Address F �J � ( City Lot Size PM iilbe Owner's Name �l b-�-f � RS[�iY Address JRV 0 U 1A1 Q L_ Phone Contractor e_ Address .31 fe License No. Phone TYPE OF WEIL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST'SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE-: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI-industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I7 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout V1V I 1 Irrigation _Approx. Depth I I Eastern Surface Seal installed by 1 _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ n� Well Destruction ❑ Well Diameter Sealing Material (top 501 Vv Depth _ Filler Material IBelow 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION f-1 REPAIR/ADDITION [.I DESTRUCTIONTRikiNo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence�"Commercial_ Other v Number of living units: Nuiriber of bedrooms d Character of soil to a depth of 3 feet V4later table depth SEPTIC TANK -❑ Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposalu Distance,to nearest: ; Well f l ` P.oundation Property Line--'-' LEACHING LINE ❑ No. & Length of lines. .. -47� T6 al length/size FILTER BED ❑ Distance r to nearest: Well ' %Foundatioh Property Line SEEPAGE PITS [ I Depth _ Size Number �+ SUMPS ❑ Distance ito nearest: t Well ` Foundation Property Line DISPOSAL PONDS ❑ 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. ^ i ; 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 issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant.51t t c I or pli quired i s tions. Com to drawing on reverse side. Signed X Title: !' Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Data (J Area J Pit or Grout Inspection tyy� i Date final Inspection by Date b Additional Comments: v— ❑ Stk 466-6781 ❑ Lodi 369-3621 . ❑ Manteca 823 ❑ Tracy 835.6385 Applicant - Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FE INFO AMOUNT DUE AMOUNT REMITTED,_w CK RECEIVED BY DATE PERMIT'NO. i {^ 1i { EH 14-28EM 13-24 IREV.i/m5) v ` / ' CCC///V - `1