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.S"Id 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 is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application i 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 Joaqui Local Health District. ` Job Address Z 9`9�+ - RVQ XJ .E,U City- Lot Size PM t 1_ Owner's Name 'E) C—h R f— 1 Address - Phone Contractor \.& 1tR1_'T r� 1prl Address ^ License No.��9Phone.G? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ v 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❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WeilExcavationDia. of Well Casing ❑ Domestic/Private .. D Gravel Pack ❑ Tracy Type of Casing Specifications ` Pl Public ❑ Other 11 Delta Depth of Grout Seal "" ' Type of Grout_. _ I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material (top 50') C>C Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION I PAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence--./Commercial_ Other r Number of living units: / Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/M} a t � P No. Compartments 9 Capagity. �' r PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest. Well LC.LL Foundation�e Ci ,Property Line7— ` LEACHING LINE o,. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line' ../n SEEPAGE PITS P- Geplh .�,d:; Size _ _ Number rr SUMPS LI 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, an t. 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 n employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatur cenifies:-the following: "I certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensa tion laws of-Cial'forniae`- The applicant all for I r uire Iris e i s, omplete drawing on reverse Ida. Signed( .�'lR�" Title: L{T�' Date: FOR DEPARTMENT USE ONLY ��[7 Application Accepted by '� ^'U/. y-�t•I r��''L Date �� —/ ^5p•% Area n y Pit or Grout Inspection by Date Final Inspectiony • ,b ( ��- Date i7 V Additional Comments: T8/.�' C��<� !r!L,1 ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 `^ INFO AMOUNT DUE AMOUNT REMITTED CASH CK ifRECEIVED BY DATE PER MIT'N0. .EH I}2a IaEV.vxsl •� /` � �� EH ta-a! 1