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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) i 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District,,?4//?- J 14Job Address _ City Lot Size / PM - Owner's Name - �, f Address I 0 F, ROS&b f 2[f 7__ Phone 1v 7 `' I Contractor r�St�sOI&S. _Address 3 22, r IS W--94-License No.a7�7 � _Phone 1 TYPE OF WELLIPUMP: NEW WELL U WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR El OTHER ❑ DISTANCE TO NE SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOU AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR REA CONSTRUCTION SPECIFIC .TIONS.' C1 Industrial ❑ Open Bottom ❑ Manteca cavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack. Ll Tra r Type o Specifications * Public hl Other Delta Depth of Grout Type of Grout ._ 1"1 Irrigation --Approx. pth I Eastern Surface Seal Installed by _ t i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter l Sealing Material (top'50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I 1 DESTRUCTION o septic system permitted if public sewer is available within 200 feet.) Al Installation will serve: Residence Other 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 j PKG. TREATMENT PLT. ❑ € - Method of Disposal Distance to nearest: Well Foundation Property Line I. iF s LEACHING LINE ❑ No. & Length of linesi Total length/size ; FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth i _Size f- Number SUMPS ❑ Distance to nearest: 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 Diktrict. Home owner,or licensed agent's signature certifies.thaJollowing: "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, I shall employ-persons subject to workman's compensa- tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. I L Signed X ��`�/ Title: eall Date: oZ 7 FOR DEPARTMENT USE ONLY Application Accepted by c Date '� Area Pit or Grout Inspection Date Final Inspection by / Date Additional Comments: . �l C Tli f«[ sN[` .�}( , L_ v",t - ❑ Stk 466-.6781 ❑ Lodi 369-3621 �❑ fv enteca 8217104 ❑ Tracy 835-6385 Applicant _.Return all copies to: Environmental Health Permit/Services 1601 E- Hazelton Ave., P.O. Box 2009, Silk., CA 95201". NO FEE INFO AMOUNT DUE AMOUNT REMITTED..-' CASH CK RECEIVED BY DATE PERMIT'NO.- +.EH 13-24 1 REVK5 ,LTD EH 14-28