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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209)'466-6781 <br /> ���=omple�tein <br /> EAR FROM DATE ISSUED <br /> Triplicate] <br /> No.District <br /> for sewage r t t con for construct <br /> and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin l Health District far a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. 5 Acres <br /> ' Lodi Lot Size PM <br /> 12991 East Col l per City <br /> Job Address 466-6711 <br /> Portside Builders Inc: Address 2714 Country Club #G Phone <br />� owner's Name 462-14$1 <br /> E 3942411 Phone <br /> Jerry Jo & ASSOCiate$_icense No. <br /> Contractor's;Name WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL OTHER 13SYSTEM REPAIR ❑ <br /> .: PROP. LINE <br /> DI <br /> INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. <br /> . <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ` <br /> FOUNDATION �- o <br /> TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> INTENDED USE <br /> Bottom ❑ Manteca Dia, of Well Excavation <br /> ❑�nd�strial ❑ Open Btt0"r racy Type of Casing Specifications <br /> �CDomesticlPrivate ❑ Gravel PackType of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> El Public <br /> Surface Seal Installed by <br /> ❑ Irrigation _�4pprox. Depth ❑ Eastern H.P. State Work Done { <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter �— Filler Material{Below 50'1 1214 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INS REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailabPeiwit in 200 feet.)ed if.public sewer is <br /> X <br /> Installation will serve: Residence Commercial— Other <br /> 3 � 35' <br /> Number of living units:�� Number of bedrooms x Water table depth <br /> m R 2 <br /> Character of soil to a depth of 3 feet: - Capacity 1200 No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg4 F/ Method of Disposal Sedimentation <br /> i PKG. TREATMENT PLT. ❑ •. � /O :,'7�: Property Line <br /> /� <br /> 1 Foundation p y <br /> Distance to nearest: Well <br /> (3) 40' Laach r T tal length/size S <br /> LEACHING-LINE [X /No. & Length of lines — 7_ <br /> Property Line <br /> FILTER BED ❑ Distance to nearest: Well /Q C? Foundation i _ p rtY <br /> Sizedumber 3 <br /> SEEPAGE PITS Depth Foundation � i Property Line <br /> SUMPS ElD'+stance to nearest: Well i <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> k rules and regulations of the San Joaquin Local Health District.lowg' work for <br /> 1 not <br /> Home owner or licensed age�nnersignature <br /> to become subjectlt workmen'srtcompensation`lawwsaof California." Contractor's or sub-contracting rmit is issued, l signsh ature <br /> employ any person in such <br /> E certifies the following:"l certify that in the performance of the work for which this permit is issued, I shall employ p <br /> ns The applicant must call for all require6rsosubject to workman's compensa- <br /> tion laws of California." <br /> I d inspections. Complete drawing on reverse side. <br /> Title: Date: <br /> Signed <br /> FOR DEP RTMENT USE ONLY � �/ t,/ �1 <br /> r ` �/ Area <br /> Date { <br /> Application Accepted by f Date - <br /> 6i)t <br /> r Grout Inspection by <br /> Date final nspection by <br /> I <br /> Additional Comments: e ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> ❑ Stk 466-8781 ❑ todi 369 3621 Stk., CA 95201 <br /> I Applicant Return all copies to: Environmental Health permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMIT"NO. <br /> I FEE AMOUNT DUE 7AMOUNT REMITTED CASH <br /> INFO <br /> 1 45.00 S, o � � i4e x/43/ gH � <br /> + EH 13-24[REV.10!631 _ - <br /> cu tLDR <br />