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1 ' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 K"^ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 71= 5�] (Complete in Triplicate) <br /> Application is hereby madJ 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'4Cl !VQ/ If R�f ��� Cit 1,0 tot Size PM <br /> r� dam, qa 701 2 t3 <br /> Owner's Nam N Address 17gjW A5L 114A , L4 Ld- Phone <br /> " Contractor Address License No. Phone <br /> TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION a SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEARE • SEPTIC TANK SEWER LINES DISPOSAL fJ 7"DT" PROP. LINE f <br /> rim F DATION AGRICULTURE WELL ____��-- —OT1iCR WELL PITS/SUMPS <br /> INTENDED USE TYPE OF L PROBLEM AREA CONS_T_RUCTION SPECIFICATIONS I <br /> ❑ Industrial >Gravel <br /> m Manteca ia- of.Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private k ❑ Tr - Type of Casing SpecificationsM Public '"J" — elta Depth of Grout Seal Type of GroutI I irrigation th I I Eastern, ace Seal Installed byRepair Work Done "❑`° """""'r""" "~ 0tWPWell Destruction, ❑ r _Sealing.Material (top 50'1 <br /> - - - -air ,. ..a.►F a r__— ___� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTIO No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will'serve:w Residence""" Commercial_ Other <br /> Number of living units: Number of bed oo s <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments r I <br /> PKG.,TREATMENT PLT. ❑ k Method of Disposal O <br /> Distance to nearest: Well Foundation Property Line d # <br /> LEACHING LINE--`*0"".No.`&Lengfh of lines Total lerigtti!§iz"e"`"�`"'� <br /> r: <br /> FILTER BED ❑ 'D <br /> istance to nearest: "Well "'"` Foundation -7 Property Line <br /> SEEPAGE PITS. I 1 +Depth Size Number I' <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> �,�v' r <br /> DISPOSAL PONDS 1-1 "`t ii- <br /> I hereby certify that I have prepared this application and that the'work'will be done it accordance with San'Joaquin county ordinances, state laws, ani i1 <br /> rules and regulations of the San Joaquin Local Health District. ,�, % I 1" <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 no <br /> employ any person in such manner as to become subject to workman's compensation law`s of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: '9 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa r <br /> tion laws of California." ' <br /> The applicant m t call for all r i:1renspections. Complete drawing on reverse side. <br /> Sig d X Tills: <br /> r ! , <br /> "- � FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ��'`C] I Area ©a <br /> Pit ar Grout inspection y Date Final Ins p tiok-byWILDate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 <br /> 1 <br /> FEE <br /> INFO A�MUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24MEV.1i05) 3+�^O` oQ <br /> EH 14-26 I <br />