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�g168 V <br /> � <br /> APPLICATION FOR PERMIT <br /> c�fL. VAIZO12- <br /> SAN JOAQIUIN LOCAL HEALTH DISTMCT <br /> f-, 16t t E. HAZEL i ON AVE., STOCKTbN, CA <br /> Telephore (2001 466.6781 <br /> PERMIT E7{f=1RES 1 YEAR FROM DATE ISSUED <br /> (Cornpicte in Triplicates <br /> j I or install tho work <br /> .This applitaiion is <br /> Applic nt co py once with h San Juaquln County Urdinarce Na.549 far sewage or permitto <br /> 1662 iorcwellltoump and he Rules and herein <br /> Regulations of he San Joaquin <br /> rte+ made <br /> Local iieatth District. <br /> 5400 East Marne Lane <br /> City �-0�..di— Lot Size 11 re PM <br /> Joh Address <br /> Frank Preiss phone <br /> — Address � � mo+< (805) <br /> Owner's Name <br /> Consultant: Staal, Gardner & Dunne, rnc. �L;cense No..NOT—A—PhOne <br /> Address <br /> NEW WELL ❑ WELL REPLACEMENT G DESTRUCTION U <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR D OTHER IN Soil Vapor SUrve <br /> PUMP INSTALLATION ❑ DI-POSAL FLO., PROP. LINE 300'— <br /> OlSTANCE TO NEAREST: SEPTIC TANK 1 OD ± -- SEWER LINES <br /> — p1T5lSUMPS <br /> FOUNDATION 100 t AGRICULTURE WELL �QQ---OTHER WELLIL Vr— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Oia.of Well Casing <br /> Dial,of Well Excavation��-- <br /> i 1 Industrial G Open Bottom Maly ca Type o!Cas.-•q none Specifications <br /> X Domestic 1 Private i3 Ptavel Pack eIltire iRterVa}ypq cf Grout vo1cla�T---- <br /> 1-1 rather CT Delta Depth of Grout Seal <br /> Public Surface Seal Instalieo by <br /> I I InaJanon —Approx. Depth I I Eastern _ — <br /> H � Slate Work Done <br /> H.P. — --^---^�— <br /> -•• Repair Wolk Done i3 Type of Pump VOlcla <br /> Sealing Material(tap 50'1 <br /> Well Castle r] Well Diamete. Filler Material IBelow 50'1 —~__— <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAII0 DDIIION I i <br /> DESTRUCTION <br /> I; availibleINO lwi within 200 feelt`ed i1 public sewer is <br /> Installation wilt serve: Residence <br /> Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> _.%Character of soil to a depth of 3 teen- Capacity No.Compartments <br /> SEPTIC TANK ❑ type/Mfg Method of Disposal <br /> PKG,TREATMENT PLT.❑ Property Line <br /> Distance to nP3rest: Well Foundation P rtY <br /> Total length!size <br /> LEACHING LINE Ll No.&Length of linos Foundation <br /> FILTER BED G DistanProperty Line <br /> cc :o W"ar"s[: Welt <br /> Sae Nur <br /> mbe <br /> SEEPAGE PITS I I Depth Foundation Pro <br /> Line <br /> — SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS 11 �� <br /> I hereby certify that I novo prepared this application and that the work will be done in accardanse with Sar.Joaquin county ordinances,state laws,and <br /> rules and regulations of the San Joaquin Local Health D3trict. Work for <br /> l not <br /> Home owner OF licensed h,ne's signar torecertifies ecome subject following.to kman' Camp <br /> fensation lhat in the ewsoof California."Cant act is hiring l or sub-contractingrmit is ssignssued.I ature <br /> e <br /> emPlaY Y Pect <br /> certifies the following: u h;na that in the pertormanc�at the work for which this permit is issued,I shall employ persons subject to workman's compensa• <br /> tion laws of California." <br /> The applicant must call fcr all required inspections.Complete drawing on reverse side. L,Zr� <br /> , Title: Registered Geologist pate: / <br /> signed X Inc. <br /> f '^wRTMENT USE ONLY <br /> or Staal, Gardnet & Dun a, FOR ty <br /> ` by William,. C ce- y Data Area_ <br /> Application Accepted by <br /> Data Final Inspection by Date <br /> Pit or Grout inspection by <br /> Additionsi d "�n <br /> Comments: -� <br /> 1-1 Stk 466-6781 Lodi 369.3621 ❑`• tcca 1123.7104 ❑Tracy 83S+.. P.O. Boz 2009. Stk.,CA 116201 <br /> plieane-Return oil copies to: Environmental Health PermitlServices 1601 E.Hazelton Ave., P. <br /> F AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY GATE PERMiT'NO. <br /> 3 - <br /> .-1341 rREV.I• <br /> • tH 11-2a - <br />