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APPLICATION .FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7601 E. HAZETON AVE.]STOCKTON, CA <br /> r Telephone (209) 466-6781 <br /> 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> application.This is <br /> Applicationishereby made to the San Joaquin L°Hance No.549 for sewage or permitN0 1862 for wellldpump and the flu/of install the oles and rk 'Regulations of the San Joaquin <br /> made incompliance with San Joaquin County Ord u <br /> Local Health District. ;I <br /> r PM <br /> Cit of Size <br /> D IVT <br /> Job Address � .: <br /> s t` Phone <br /> Address = ` , ,/ <br /> Owner's Name iM /2 <br /> r f .s License r4o.0 3; 673_� —�- Pham <br /> Contractor t DESTRUCTION ❑ <br /> TYPE OF WE L /P M NEW WELL ❑ WELL REPLACEMENT <br /> SYSTEM REPAIR ❑ <br /> SEWER LINES OTHER ❑ <br /> PUMP INSTALLATION ❑ �N DISPOSAL FLD. PROP. LINE <br /> r —�-- <br /> DISTANCE TO NEAREST:ISEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> <FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ? ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> T ing <br /> i 1-1 Domestic/Private { ;❑ Gravel Pack ❑ Tracy Type ICas 'Type of Grout — <br /> 1_l Other ' 71 Delta Depth of Grout Seal _ <br /> ❑ Public Surface Seal Installed by <br /> I I irrigation w _.Approx. Depth I i Eastern O <br /> State Work Done <br /> Repair Work Done I2 Type of Pump <br /> Sealing Material (Top 50' <br /> Well Destruction ❑ Well Diameter Filler Material (Belo 50') <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION , DESTRUCTION l } available septic permitted if public sewer is <br /> ailablew thin 200 feetl /r <br /> installation will serve:"''_Residence f� Commercial_ Other . <br /> Number of living units: -. Number of bedrooms Water table depth <br /> Character of-.soil to a depth of 3 feet: XIIII No. Compartments _ <br /> ❑ Type/Mfg Capacity N��— _ - <br /> i SEPTIC TANK# ._ �.._ J' "z ,""jyMethod of Disposal <br /> PKG. TREATMENT PLT.'❑r 1 WellProperty Line 1 <br /> Distance to nearest " Foundation /) <br /> „F <br /> �M Total length/size <br /> f LEACHING LINE ❑1 . No. & Length of lines property Line <br /> ❑ Distance to nearest: ' <br /> Wall— Fo>FMndation <br /> j FILTER BED _- <br /> I W � <br /> ! �M Number <br /> SEEPAGE P I l r6epth, Size <br /> t (Q1L Foundation _ = Property Line <br /> MPS :,L'� Distance to nearest: Well <br /> DISPOSAL PONDS '❑ <br /> S nd that the work will b�4e done in accordance with San Joaquin county ordinances, <br /> I hereby certify that V have prepared this.application astate laws, and <br /> [ rules and regulations'of the San Joaquin Local Health District. M' a,f work for this <br /> Homo owner aor rson inss�Ch manriergas torbecome sub act e certifies the Ito wlng: 111 orkman's coyth t in the mpensation lawsoof California."rmance Contractor's lhiring oro sub-cont act ng signlature <br /> emp y y p ersons sub"act to workman's compensa <br /> @@@ certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> The applicant. u t II f r alt r ` 're inspections:C plate drawing a rah arse sides <br /> r Title: <br /> Date: <br /> Signed p. <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> Date Area <br /> Application Accepted by.. ) <br /> Final Inspection by Date I <br /> Pit or Grout Inspection by �Mntc, 823-7104 <br /> Date f� <br /> Additional Comments: p Tracy 835 6385 <br /> r ❑ Stk 466-6781 ❑ Lodi 369 362 ! <br /> Applicant - Return all copies to: Environmental Health PermitlServices E.�Hazelton Ave., P.O. Box 2009, 5tk., CA 95291 <br /> CK# I RECEIVED 8Y DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> I��NjjF��O <br /> + EN 13-241REV"i�H5) .]f\ '��-�� �~ � <br /> i <br /> -EH 14-26 �� <br />