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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZE' TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SEP 13 1n^ (Complete,in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the %Rk$1�J iRVJ 6ppIicati.n 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. l / �/ t Job Address � � l b� ��1JFIL 7 � City �`I3p&J Lot Size PM Owner's Name Address Roo 2 Il4, (",,�q&ZLY R Phone !RPV7f 3 Contractor 4ik Address 1 License No. s Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR P OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION_ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing l DomestictPrivat'e„ "•"❑ Gravel Pack El Tracy _v Type of Casing Specifications f M Public FI-Other ❑ Delta, Depth of Grout Sea! Type of Grout a._. i l irrigation _._Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done' ❑ Type of Pump IW4 H.P. a3 State,Work Done ' 141�e Me" Well Destruction ❑ Well Diameter _� Sealing Materia! )top 50') Depth = � f Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION E I o(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms r Q Character of soil to a depth of 3 feet: Water table depth SEPTIC..TANK,__ _ C]_, Type/Mfg- Capacity- No. Compartments PKG. TREATMENT PLT. ❑ ° Method of Disposal Distance to nearest: Well Foundation rf Property Line I + -LEACHING LINE -Ll No. & Length of lines Total length/size FILTER BED '❑ Distance to nearest: Well Foundation/ Property Line _ 1 SEEPAGE PITS ., I I Depth I Size Number SUMPS _.� L-i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f � 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 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 employ any per n such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo! win :"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- f tion laws of C ifor Pa. _ �. The applic t t call for all r q red ins cf ris: omplete drawidi on rev r side. - — Signed X Title: A-- Date: R DEPARTMENT USE ONLY f� Application Accepted by _ Date �'�// � ..Area Pit or Grout Inspection by Date Final inspection by Date Additional Comments: ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. l + EH 1 -241REV.rigs) EH 144-26 1_71 I