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x <br /> APPLICATION FOR PERMIT <br /> i' SAN JOAQUiI! LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. CO <br /> Telephone (209) 466-6781` _ DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ' <br /> rein <br /> Application is hereby madate otoithma'deninocompliancelwHthlSanth gJoaquin County istricp0 dinancceermit to cNo5t549tfordsewageSorlNoth1862rforewell/pump <br /> described. <br /> and the Rules and Re the San 0oaquin Local Health Distric .4 <br /> 1 Subdivision Name <br /> Job Address Phone <br /> Address <br /> Owner's Name Phone 6009---i <br /> Contractor's Name -} License No. <br /> REPLACEMENT 0 DESTRUCTION WELL <br /> TYPE OF WELL/PUMP WORK: NEW JIWELL DPUMP INSThLATICNU <br /> SYSTEM REPAIR 0 OTHER <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ ,f- __ PITS/SUMPS <br /> FOUNDATION SEWER LINES <br /> AGRICULTURE WELL _ OTHER WELL 0 <br /> ► <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYFE'OF WELL; PROBL� EM AREA Dia. of Weil Excavation <br /> Industrial U Open'.Bottow, Manteca <br /> gg Dia. of Well Casing <br /> ' U DomesticlPrivate F-1 Gravel Packi �Tracy_ ? <br /> Public G Other Delta Type of Casing <br /> LJ Irrigation Apprbx. 0 Eastern Specifications d <br /> Cathodic Protection , <br /> Depth Depth of Grout Seal <br /> Geophysical Type of Grout <br /> Surface Seal Installed by <br /> Other ' <br /> H P State Work Done <br /> Repair Work Done Q Type of Pump <br /> Sealing Material (tap 50') � <br /> well Destruction U Well DiameterFiller Materia} (Below 50') <br /> Depth <br /> No septicitank or seepage pit-permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L� REPAIR/ADDITION ( —avai-lab'le-withir`206-feet:) <br /> Commercial 'Other ,,rrrtaN.�Iss'.r- <br /> installation will serve: Residence F t• `Lot size <br /> - Number of bedrooms / } € } <br /> Number of living uiits: _ _ r Water table depth./ ! <br /> Character of soil to a depth of13 feet: <br /> No. Compartments <br /> SEPTIC TANK F1 Type/Mfg <br /> Capacity <br /> pacity ° <br /> Capacity — Method of Disposal <br /> PKG. TREATMENT PLT. F1 Type/Mfg aundation; Property Line __�_M --A <br /> SEWAGE SYSTEM x Das,tance_tomneares.t: ,„.Wel _ , ; , <br /> DESTRUCTION <br /> o. & Length of lines , -' .Total lengthlsize <br /> N <br /> LEACHING LINE U Foundation Property Line <br /> Distance to nearest: <br /> FILTER Well t_. t <br /> BED'- ❑ - b' IOr= b <br /> 20tZ <br /> lE1t+r ll2t 3;� Number .- 1. . <br /> T't i SEEPAGE PITS =; e I w depth Size "} Property Line AV— <br /> oundattign <br /> w SUMPS } } Ois'ta ce to,nearest: Wel} <br /> 7" DI'S'POSAL PONDS <br /> one- <br /> f s <br /> I�hereby that I have prepared this application and that quip Loci H abth'Disiri accordance with San Joaquin coun y <br /> performance of the work for which M s 1 <br /> +' ordinances, state laws, and rules and regulations of the San Local HeaTth'Oislrict. <br /> Home owner.or licensed agent's signature certifies thp <br /> suchfmannernas tobecomesubjectthdt �`tohwokman5 compensation laws of California." <br /> r perm is issued, I shall not employ any person f- ' I certify,that in the performance of the work for which <br /> i r Contractor's hiring or sub-contracting si nature'certifie`5 the fohl,owinga",w <br /> t..,_ <br /> f this permit Zas issued, I shall employ persons^-subject to work an'srcompensation laws`of California. <br /> The applicant mu call for all required in p tions. Complete drawing 'nside. pate: <br /> t .+ Title: <br /> Signed X <br /> s OR DEPARTMENT USE ONLY ,Area <br /> #' Application Accepted by x Lodi 369-3621 <br /> Additions Comments:—_. - + Manteca 823-7104 <br /> �r 1 I Date <br /> Pi.t"or Grout }Inspection b R pate Tracy.' 835-6385 <br /> F 1, .c.,,t..,. - <br /> _ _Final Inspection by k <br /> y i <br /> aApplicant Return all copies �o: Environ ental He�lth Permit,/.Services 1601�_,E. azelton Ave., P.O. Box PO09, St k., C 95201 <br /> .' I tf - PERMIT NO. <br /> AMOUNT^',REMITTED �.: RECEIVED 8Y DATE <br /> FEE- BASE AMOUNT DUE ti g <br /> IN <br /> "ER-1'3=2'4—REV'TO'l82 <br /> 14-26 <br />