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{ APPLICATION FOR PERMIT 4� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 of the San Joaquin Local Health District.. Job Address City Lot Size PM 1 Owner's Name teak Address ^W Phone F�Z� Contractor �' 'Address ' Zs �'• � License No. S12 _1 Phone yd I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationp Dia. of Well Casing N ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing /y Specifications M Public ,mow17OtYr F1Delta Depth of Grout Seal 3 Type of Grout I I Irrigation 167Approx. Depth l I Eastern Surface Seal Installed by !t41Kt0_ - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I ) DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other r Number of linin its: Number of bedrooms i O Character of soil to a e f 3 feet: a e depth SEPTIC TANK C1Type/Mfg Ca No. Compartments PKG. TREATMENT PLT. 11 Method of Disposal Distance to nearest: on Property Line LEACHING LINE >EIN o. & of lines Total length s FILTER BED ance to nearest: Well Foundation Property Line SEEPAGE P I I Depth Size Number SUMP ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 C rnia." The applic t m st call for all q 'ed i on . Complete drawing on r arse side. / 7 Signed X ill ' Date: ` /Z 1a OR ARTMENT USE ONLY 1 Application Accepted by Date / + Area1 Pit or Grout Inspection by6�0I Date Final Inspection by Date 'Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 I ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO H + EH1 -24IREV.limb) ^r~ �3S EH 144-28