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APPLICATION'fFOR,,PERMIT
<br /> SAN JOAQIJIN,zL•O.C-ALHEA�TH DISTRICT
<br /> 1601 E. HAZEL T ON'.AVE., STOCKTON, CA
<br /> Telephone
<br /> (209)..466-676'i" y
<br /> -e�8 R1 � '�� X31 '+ �Q SJ�3. m o P,ofmi! ,4
<br /> PERMIT EXPIRES;1'YEAR,FROM„OATE,ISS.UEDr4i,: 1'tec�ic�
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<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desCribetl: This application is
<br /> made:in`coinplianc;6With,San,Joaquin,.County_OrdinanceNo 549.fotsewage-or,No.-X1862forwellLpump�r)d-I ajRulesand'+RegulationsoftheSanrdoaquin
<br /> Local Health District.iC;t tl,..-? ,E3 +J 3i''.t:" �? +c. rirc: Vhf^ �a ;,tit2�+2 ?�uf?t� !°# �� vv" P!; t0 $C F.•}9SatitaiU r?
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<br /> rsrs�9F 1
<br /> ry L .c City Of,SiZe�
<br /> Job Address
<br /> hone
<br /> Owner's Name ry r -
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<br /> Lice ;No Phone a��
<br /> Contractor's,Name f � �° I -
<br /> -Pse
<br /> ':No.OFWELL/PUMP: EW WELL Q WELL REPLACEMENT ❑ DESTRUCTION
<br /> - - r
<br /> s-- ❑ _.-. 4 SYSTEM•REPAIR ❑' OTHER-❑
<br /> 1 ; LINE
<br /> f DISPOSAL FCD:— P TSpSIUMP
<br /> PCINIP INSTALLATION
<br /> DISTANCE TO,NEAREST.•SEPTIC TANK - -SEWER-LINES-
<br /> Y AGRICULTURE WELL OTHER WELL—
<br /> FOUNDATION i
<br /> FOUNDATION !
<br /> INTENDED USE 1 TYPE OF WELL
<br /> "PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> r ❑Jndustrial a f__ (:]-open Bottom i--.. 'E].Manteca
<br /> Dia. of Well Excavation •-
<br /> Dia.'of Well Casing.
<br /> i ;Type of Casing Specifications
<br /> 1-1 _omestic/Private ❑Gravel Pack i ❑ Tracy g f
<br /> D - -4
<br /> _. Type o Grout
<br /> 0 Public { Grout Seal Yp
<br /> i ❑,Other i El Delta Depth of 1
<br /> I - ❑ Irrigation I- JApprox -Depth ;❑ Eastern ' Surface Seal Installed by l�
<br /> 9 Repair Work Done ; ❑ ; Type of Pump
<br /> 'Sealing Mater, State Work,Done
<br /> al (top
<br /> s- i!
<br /> it Well,Destruction �❑ Well Diameter `�?
<br /> I s
<br /> 'Filler Material (Below 50'1
<br /> Depth
<br /> 4..
<br /> i ;TYPE OF SEPTIC WORK: NEW INSTALLATION © :REPAIR/ADDITION ❑ DESTRUCTION ❑ m pe
<br /> alvailableiwihne200 feetrmi�led if public sewer is.
<br /> I
<br /> Installation will serve: 1,Residence Cbmmercial Other
<br /> Number of living units: Number of bedrooms
<br /> -Character of soil to-a depth of 3lfeet:,
<br /> -Water table depth
<br /> SEPTIC TANK, ❑,ITYpe/Mfg ' I Compartments
<br /> Capacity No i
<br /> tl Method of Disposal,
<br /> PKG. TREATMENT PLT: ❑ $
<br /> i Ji_i I Foundation Property Line'
<br /> p. Distance to nearest.'- Well
<br /> i LEACHING LINE ❑ .No & L' L
<br /> en th of lines Total length/size
<br /> ig i ty
<br /> Properine
<br /> 1
<br /> I f FILTER BED "r `" ❑ Distance to nearest: ell Foundation _ i ;
<br /> -:_ - F
<br /> !SEEPAGE ITS r ❑ !Depth ,E � -Size # � Number
<br /> •M � - , _ � _ .
<br /> �' -i Foundation "`-Property-Line w�""`"�"`
<br /> " t SUMPS i , ❑ ;Distance-to nearest `Well`
<br /> DISPOSAL PONDS ❑
<br /> I hereby certify that i ha~a prepared this application and that the iwork will be done in accordance with San Joaquin county oidinances state laws, and
<br /> rules and,regulations of the San-Joaquin-Local Health District. 1
<br /> I ;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 /> r - employ any-person in•such manner as to become subject to workman's compensation laws of California.".Contractor' ]tiring or,sub-contracting signature-
<br /> employ
<br /> the followiperson in "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 /> }-
<br /> } i The applicant must all fof ui d in ions Complete drawing,on reverse side
<br /> 1 �. f '. t .� Date: IJ /
<br /> i Title: -
<br /> Signed
<br /> FOR DEPARTM NT USE ONLY j^F� is / fF�
<br /> Date �� Area {
<br /> ! 1 Application Accepted by _ ": _ _ ' r
<br /> i .... Date s Y i r- Inspection by } f 9_'_V_ �9 Date /�—
<br /> Pit or Grout Inspection by
<br /> a
<br /> AV bkl�%M
<br /> o f 1
<br /> Additional Comments � Cs�7Csf`vst'Cf�nr _
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<br /> ±.❑ Stk 4666781 CJ Lodi 3621 C]-Manteca 823 r ❑,Tracy 6356385 �,f/ 117Y C9TXIT�7af';
<br /> Applicant Return all copies to: Environmental Health PermitlSernces 1601E Hazelton Ave., P 0. box 2009,,Stk.; GA 95201 Q ?
<br /> i exiCl'
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<br /> 3 FE -CK RECEI gy, DATE`: PERMlT''NO. i
<br /> E -rAMOLINT SUE I-AMDUNT REMITTEb t W1
<br /> INFO r- -
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<br /> EH 1&24(REV.10/831 I . 5 1 _ .;•. i I7-t .g SS _...
<br /> t EH 14-28 i - _ ,.. ...._.. _
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