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109 <br /> APPLICATION FOR PERMIT �- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT fi <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 o <br /> ES 1 YEAR FROM DATE ISSUED <br /> PERMIT EXPIRES €� <br /> (Complete in Triplicate) fi V�/� a X989 <br /> ibed. This application is <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and/or install and the work g� „f the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a vi&�� try <br /> Local Health District. (IDI <br /> 3 / �� Lot sizertl PM <br /> (� City—12 <br /> Joh Address � I p� <br /> Phone N/ L <br /> Q Address <br /> Owner's Name (� f <br /> Address � J ti License fVo.�Phone <br /> Contractor " <br /> TYPE OF WELL/PUMP: �NEWWELL WELL REPLACEMEN ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑PUMP OOTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK d`a SEWER LINES DISPOSAL FLD. PROP. LINE <br /> --- FOUNDATION AGRICULTURE WELL OTHER WELL _ PiT5/SUMPS {, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI Dia. of Well Casing <br /> p dustrial ❑ Open Bottom Q Manteca ,7Dia. ofWell Excavati r/�t�nomf Casin Specifications f� �JmesticlPrivate Gravel Pack L7LracY gType of Grout rfl Public (� Other Cl Delta of Grout Seal <br /> A rox. Depth I 1 Eastern Surface Seal Installed by_Q y�� <br /> - <br /> I I Irrigation � Pp >? <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done �n <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') —� <br /> TYPE OF SEPTIC WORK:• NEW INSTALLATION t REPAIRIADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet,I <br /> t <br /> Installation will serve: Residence— Commercial— Other <br /> • Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity_ No. Compartments <br /> PKC. TREATMENT PLT. L1Method 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 i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line C <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health Di%trict- <br /> y that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certif <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 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- <br /> tion laws of California " <br /> The applicant m call to all re ire pe ions. Complete drawing7A��— <br /> l155, <br /> Signed Xitle: Date: L <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date _Area �[ <br /> Pit or Grout Inspection by <br /> Date Final Ins tipn by Date 9 7 <br /> Additional Comments: h <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 635-6385 <br /> Applicant - Return all copies; <br /> �`V�vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> _ <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO JI^ CASH /y�, <br /> -EH 13-241p@V.t/H51 • <br /> EH 14-2$ <br />