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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> [PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ' <br /> permitcal Health District for a to construct and/or installthe <br /> the Rules and rk (Regulations of the San Joaquin <br /> Application is hereby made to the San Joa .This application is <br /> quinord ordinance No.549 for sewage or No. 1862 for welllpump <br /> made in compliance with San Joaquin County ' <br /> Local Health District. (y G, PM -- t <br /> d� Azle � � � l fJr�G� a City Lot Size � <br /> O <br /> Job Address Phone <br /> j <br /> Z <br /> Owner's Name �Ph n <br /> /,76 Address pX q� FJ _License No. ; 33 <br /> 35 <br /> PSiIS yGve'll II Y.-1 Address " r���' 0 DESTRUCTION.64' <br /> ont ctor �� WELL REPLACEMENT ❑ <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP, LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. <br /> SEWER LINES —� .OTHER WELL PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK ---- AGRICULTURE WELL <br /> FOUNDATION ��- <br /> TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> kNTENDEp USE ❑.Manteca Dia. of Well Excavation <br /> El Industrial El Open Bottom Type of Casing Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Grout ----- <br /> ❑ DomesticlPrivate .4 n Delta Depth of Grout Seal <br /> r f"1 Public (7 Other <br /> f Surface Seal installed by <br /> t,l Irrigation- `.Appr 7• Depth I ! Eastern State Work Done — <br /> r H.P. . <br /> Repair Work Done ❑ Type of Pump >j--1� �; Sealing Material itop 50'1 <br /> Well Destruction B�Well Diameter �a� ' <br /> Depth t Filler Material.(Below 50') <br /> public sewer is <br /> l available within 200 feet./ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION l.1 DESTRUCTION l i INo septic system permitted it <br /> Installation will sere: Residence y <br /> Commercial— Other <br /> Number of living units: <br /> Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity_� No. Compartments <br /> I e/ <br /> T <br /> ❑ ypMfg 1 \� <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT.❑ Foundation��--;Property.Line_�— <br /> Distance to nearest: Well <br /> 4 I <br /> Total length/size <br /> LEACHING LINE ❑ No. &r Length of lines Property Line <br /> I Faundatiom -� <br /> FILTER BED F] Distance to nearest: Well <br /> " Size Number <br /> SEEPAGE PITS It Depth Foundation Property Line <br /> SUMPS Ll Distance to nearest: Well' <br /> state laws, and <br /> DISPOSAL PONDS <br /> � and that the work will be done in accordance with San Joaquin county ordinances, <br /> I hereby certify that I have prepared this application <br /> El <br /> t not <br /> rules and regulations of the.San Joaquin Local Health Di?trict.s the fg y that in the work for which this <br /> sig at re <br /> Home owner or licensed agent's signature Ceome subject workman'srtcompensation lawsofCalifon aha otrac�ons hiringor <br /> c t w sub-oktman's comperrylit is issued, I lensa- <br /> I employ any person in such manner as to be <br /> certifies the following: "I certify that; the performance of the work for which this permit is issued, f she employ <br /> tion laws of California." t� <br /> applicant st. all for all requirad nspections. Complete drawing on7 averse side. , <br /> The app Date: <br /> Title: !!! <br /> Signed X <br /> Fo Ep ENT USE ONLY Q <br /> Date Area <br /> Application Accepted by 1~ � Data <br /> Date. Final Inspacbon by <br /> Pit or Grout Inspection by <br /> F.' <br /> Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 Stk., CA 95201 <br /> ❑ Stk 466-6781 ❑ Lodi ,369 3&21 <br /> Environmental Health Permit/services 1601 E. Hazelton Ave_ P.O. B <br /> Applicant- Return all copies to: ox 2 , <br /> FEE. AMOUNT RUE AMOUNT REMITTER <br /> K RECEIVED BY OATS P£RMIT'NO. <br /> INFO ko r2 5 <br /> + EH 13-24(REV.5/H 5) <br /> EH 14-26 <br />