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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations o1 the San Joaquin Local Health District. Job AddrGessy r RJ City Lot Sizet ) CIIW PM k Owner's Name. A�12 . Address LA 9 ! ,-QA Phone Wr �0 Contract Address c & License Noi. Phone (29 TYPE OF WELL/PUMP: " NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑, PUMP INSTALLATION ❑ SYSTEM,REPAIR-E] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f2" r° DISPOSAL FLD:-, -X- ' .PROP.:LINE.f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA *CONSTRUCTION SPECIFICATIONS k' ❑ Industrial ❑ Open Bottom ❑ Manteca "Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type-of Grout _ I I Irrigation Approx. Depth I.) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Ma erial{top 50'1 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION M—DESTRUCTION l I INo septic system permitted if public sewer is I"1available within 200 feet.) Installation will serve: Residence X_ Commercial " 01#0e Number of living units: Number of edroom's 15 Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK Type/Mfg 4&VQ Capacity 00 No. Compartments PKG. TREATMENT PLT. ❑ t ..E _' Method of Disposal Distance to nearest: Well SHO Foundation Propeirty.1-ine LEACHING LINE No. & Length of lines _ "_' `Total length/size X FILTER BED ❑ Distance to nearest: Well ,5Q____ Foundation� Property Line rf SEEPAGE PITS Dept<c25 Size Number. _ i 4 SUMPS L1Distanceto neatest: Well o� Foundation Property Line 1' DISPOSAL PONDS ❑ "3 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 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,l shall employ persons subject to workman's compensa- tion laws of California." Ik The applicant tcall fo req 'red inspections. Complete drawing on reverses y (� Signed Title;. A Date: 1 u 0 FOR.DEPARTMENT USE ONLY Application Accepted by Date Area ' Pit or Grout Inspection by to Final Inspection by �`,W Date Additional Comments: O 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 . FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, *.Em 1 *24(NEV.r/95) EH 144-2a II A