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} <br /> APPLICATION FOR. PERMIT <br /> S i <br /> SAN JOAQUIN LOCAL 1­1161-TH DISTRICT ` �1H <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> s <br /> 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 <br /> 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 <br /> Local Health District. <br /> Job Address Cr ! - Gity s" °`N Lot Sire_ 60 x zss— PM <br /> Owner's Name r� Address s2 "� et Phone <br /> - <br /> 'Contractor t� Address License No. Phone <br /> .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LIN <br /> FOUNDATION AGRICULTURE WELL, OTHER WELL -�" J SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRl1CTIOUN PECINNS F <br /> ❑ Industriai ❑ Open Bottom ❑ Manteca Dia_-of°Welt Excavation Dia. of Well Casing <br /> ❑ Domestic/Private, ❑ Gravel Pack ❑ Tra Type of Casing Specifications <br /> F] Public ❑ Other 1 Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation ox. Depth i I Eastern Surface Seal Installed by w - <br /> _ t <br /> Repair Work Done ype of Pump y H.P. — - - State Work Done_ <br /> Well Destr ' n ❑ Well Diameter Sealing Material Itop,�50'1 ; <br /> Depth I Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIRIADDITION (.1 DESTRUCTION - fNo,septic-system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence Coritmercial—a Other " <br /> 4 Number of living units: Number of bedrooms <br /> 'i I <br /> Character of soil to a depth of.3 feet: i Water table depth <br /> SEPTIC TANK" ❑ Type/Mfg Cabacity _No. Compartments <br /> PKG. TREATMENT PLT. 1711 _ .,� � � '•� � fNethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines .Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS l 1 Depth Size �� — Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line ` <br /> DISPOSAL PONDS ❑ 4 '1RJ <br /> I hereby certify that I have prepared this application and that the work will be dohe in.accordance-with-San_Joaquin-county-ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall,employ persons subject to workman's compensa- <br /> tion laws of California." } � <br /> T icant must call all r ed in pections. Complete drawing on reverse side. <br /> a <br /> 9 ./ 7 <br /> Signed X Title: "� Date: <br /> FOR DEPARTMENTI'USE ONLY <br /> Application Accepted by �p Date rea fs� <br /> i Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments:. `�X~ <br /> ❑ Stk 466-6781 ❑ Lodi :369-3al ❑ Manteca 823-7104 ❑,T 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUES AMOUNT REMITTED CK 40 !p RECEIVED BY DATE PERMIT'NO. <br /> INFO 11 <br /> �1 'l Q�' (� �j <br />'s r EH 14-28 REV.t m 51 a fJ 3 �d f� ,�"'A V� Cl1 �C>`� ��r <br /> EH N-2e �l <br />� f� <br />