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APPLICATION FOR PERMIT -7 <br /> AQUIN LOCAL HEALTH DISTRICT <br /> SAN JO - <br /> 1 1601 E. HAZELTON AVE., STOCKTON, CA <br /> } Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED <br /> ' (Complete in Triplicate) <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 wait/pump and the Rules and Regulations of the San Joaquin <br /> 'Local-Health District. c 1 <br />- " , - 9771 1 . H i 1dreth Stkn Lot.Size PM <br /> - `k w city <br /> Job Address _ <br /> j Richard Ensfninger PO Box 7414 Stocktan 95207 Phone 931-0343 <br /> Address <br /> Owner's Name 46�-6597 <br /> E Clark Wall *371560 -Phone <br />` Contractor's Name <br /> License No. <br /> I! TYPE OF ELL/PUMP: NEIN WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION DISPOSAL FLD. PROP. LINE 401' —J <br /> ! SEWER LINES _�— <br /> DISTANCE TO NEAREST: SEPTIC TANK 1001 PITS/SUMPS — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL. <br /> PROBLEM CONSTRUCTION SPECIFI Tt ! pia. of Well'Cing 5/8 n <br /> ❑ industrial ❑ Open Bottom 0 Manteca Dia.'of Well Excavation Specifications- <br /> ` Gravel Pack ❑ Tracy Type_of Casingw _ r <br /> r Domestic/Private Depth of Grout Seal 50_L_ a of Grout <br /> ❑ Other C1 Delta <br /> ❑ Public . Surface Seal Installed by A-3 <br /> - <br /> �pprax. Depth ❑ Eastern F <br /> ❑ Irrigation _ State Wok Done h <br /> _° <br /> Repair Work Done 13 Type of Pump —$13 1 H.P.— Sealing Material Itop 501 <br /> Well Destruction ❑ Well Diameter Filler Material(Below 501 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ flEPAIRIADDITION ❑. DESTRUCT100 ❑ aNailable1within 20stem 0 feet.) if public sewer Is <br /> I Installation will serve: Residence— Commerdial— Other •ate <br /> I Number of living units: Number of bedrooms Water table depth <br /> I Character of soil to a depth of 3 feet: -��-% No. Compartments <br /> j el Mfg - - Capacity��- <br /> I SEPTIC TANK ❑ TYp �. Method of Disposal <br /> PKG. TREATMENT PLT.O. ..* r <br /> D'+stance to nearest: Well <br /> Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED <br /> El Distance to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE PITS,.# ❑ Depth Foundation Property Line <br /> SUMPS D' Distance to nearest: Well <br /> DISPOSAL PONDS f f❑ Z b 1 <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 District. work for <br /> Home owner orlicensed <br /> such mannsignature�omfe sub a-t Ito wlng:.'.1 certify that in the orkman's compensation lawsoof California."'Contractor's lh rng1 or sub-cant act nglsignlatuot. <br /> re <br /> employ y Pe <br /> certifies the following: "I cern that in the o ance.oth wok f hich�hs pe it is issued,I shall employ persons subject to workman's cormpensa- <br /> tion laws of California." -�- <br /> k The applica u call r at req 're n ct' s. s td dr Ing on revev�e'si k a 1 4 Sept. 1984 <br /> Date: <br /> itle: <br /> f Signed <br /> FOR DEPARTMENT USE ONLY <br /> i Date rea / <br /> Application Accepted by Date U <br /> Final inspection by <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> C11112009, Stk., CA 95201 <br /> Stk 466-6781 Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 <br /> r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box <br /> I CK# DATE PERMIT N0." <br /> FEE CASH <br /> RECEIVER 8Y _ <br /> I INFO AMOUNT DUE AMOUNT <br /> REMITTED <br /> + EH 13-24(REV.101931 <br /> LY ti7A <br />