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4 r � APPLICATION FOH PERMIT SAN JOAQUIN LOCAL:HEALTH.DISTRICT 1601 E: HAZEL i ON AVE., ;STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 Cnunty Ordnance No, 549 for sewage or No. 1862 for well!pump anti the Ruies and Regulations of the San Joaquin Local Health District. Job Address SOD ZA_cr la _h' �ihC l�Gkrf City er Lot Size PM Owner's Na a 1> ,y 0r l f',A*" Ort"Address d `w� 1190 S% Phone(3 Contractor' u' l I�`" Address.+ . — ,_ ,- License No. c _ Phone /6 I -rf±?F TYPE OF WELL/PUMP: NEW WELL ❑ ' WELL REPLACEMENT t-j DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR i] OTHER fD: Bari+1Q S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 3fl PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. F, Domestic/Private C1 Gravel Pack J!5 Tracy Type of Casing Specifications F: Public F! Other 7 Delta Depth of Grout Seal Type of Grout _ Wit lahon Approx. Depth Eastern Surface Seal Installed bye W -�rQ�441/V G Repair Work Done i= Type of Pump H.P. State Work Done � Well Destruction ❑ Well Diameter Sealing Materia! {top 50.1 AF,4r CFM 0A1 7 ' d reOuT" 4, 5,1 i Depth v �� Filler Material 1Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I' DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.( Installation will serve: Residence Commercial_ Other # I Number of living units: Number of bedrooms J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I i 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c or all requ- inspections. Complete drawing on reverse side. Signed X Title: 6e 4) f-7 Date: F EPARTMENT.USE ONLY 1y/ �j `�^, �� ) Application Accepted by Date ` t� ' L✓ Area ip Pit or Grout Inspection by Data Final Inspection by Data Additional Comments: Sag— O Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835.6385 Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Haietton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT-REMITTED CASH RECEIVED By DATE PERMI7'NO. . E 14-29{AEV,r i x si 1 L l T L ✓ �� EMN 1�•2d i wy - - - .