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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT PERMIT N0. <br /> 1601 E. HAZ€LTON AVE_ STOCKTON, CA <br /> Telephone (209) 466-6781 DATE ISSUED <br /> 1 ' <br /> PERMIT EXPIRES I- YEAR FROM DATE ISSUED r <br /> ' (Complete in Triplicate) . <br /> l the <br /> rein <br /> Application is hereby made to the SeninocomtniLocal <br /> wHthlSanth OJoaquin County pOrdinance ermit to cNo. 549tfor dsewage sorl.No. 1862rfor ewell/pump <br /> described. This application is mad2 p <br /> and the Rules and Regulation of the San Joaquin Local Health District. <br /> ^7 Subdivision Name J <br /> Job Address a� hone ! <br /> Owner's Nam Phone <br /> License No. <br /> Contractor's Name <br /> DESTRUCTION <br /> i <br /> TYPE OF WELL/PUMP WORK: NEW ELL WELL REPLACEMENT ❑ ❑ 4 <br /> PUMP 'INSTALLATION �_i< SYSTEM REPAIR ❑ OTHER ❑ �J 9J r <br /> eq I DISPOSAL FLO. PROP. LINE L f <br /> C ° <br /> DdSTANCEaTO NEAREST: SEWER LINES SEPTIC TANK OTHER,6 ELL, _- �1� PITS/SUMPS <br /> `- y ,y <br /> r FOUNDATION AGRICULTURE WELL _ <br /> � EM <br /> PR06LAREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE^,OF-WELL Diaof Well Excavation <br /> Industrial U Open Bottom anteca , s <br /> U Domestic/Private 0 Gravel Pack ❑Tracy Dia. of Well Casing------ <br /> Public ❑Other{ ❑Del to Type of Casing <br /> Li Irrigation�Approx. ❑Eastern Specifications e , <br /> Depth Depth of Grout Seal <br /> ❑Cathodic Protection p : <br /> ❑ ! Type of Grout <br /> Geophysical <br /> r -Surface Seal Installed by <br />` ❑Other . <br /> Type of Pump _� H•p Stat&Wor&Do e <br /> Repair Work Done ❑ Yp I to 50'_) <br /> Sealing Material ( p <br /> Well Destruction ❑ Well Diameter I_�_� Filler Material (Below <br /> IE Depth E <br /> REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ avai ''able vtithan. 200 feet.} <br /> Installation will serve: Residence Commercial Other_ � Lot size <br /> Number of living units: Number of.bedrooms Water.table depth- <br /> Character of sail to a depth of i3 feet: Ca acit No. Compartments` <br /> SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal: <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Foundation �~ Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well .� ��- <br /> ❑ ;- ` - <br /> DESTRUCTION Total length/size <br /> LEACHING LINE ❑} No. & Length of lines Property Line <br /> 1 ❑ Foundation —9 <br /> ce <br /> FILTER BED Distanto nearest: Well ' <br /> ❑ Depth <br /> SEEPAGE,PITS _� Size _+ u <br /> Number f <br /> > Foundation �-Property Cine <br /> SUMPS Distance to nearest: Well <br /> x + �► <br /> DISPOSAL PONDS ❑ i <br /> ll <br /> one in <br /> anc <br /> I hereby certify that I have <br /> preparedthis <br /> re�ulaptPonsaof_the SanhJoaqulnwLocalork �HealthdDistricterformancewofhthenwoOkQfor whichuin this, <br /> ordinances, state laws, and rules a 9 e compensation laws of California." <br /> Home owner or licensed agent's signature certifies the fo3lawing: I certify that p <br /> I certify that in the performance of the work for which <br /> permit is issued, I shall not employ any person in such manner as to become subject workman comp <br /> Contractor's hiring or sub-contracting signature certifies the following: " <br /> this permit is issued, 1 shall employ per ns subject to workman's compensateoersewside California." <br /> The applicant inspections. Complete dra 9 Date: <br /> Signed <br /> Titre: <br /> ^�- - <br /> OR/DE TMEN USE ONLY A /} l ❑ Stk 466-6781 <br /> �t <br /> Application c ted by rea ❑ Lodi 369-3621 <br /> Additional Comments: Date L Manteca 823-7104 <br /> Pit or Grout Inspection'lb Date <br /> ❑ Tracy 835-6385 <br /> Final Inspection by <br /> - Return all copies;tc: ircnmental Health Permit/ `ices 160 ?elton ve.,- P:O. Box 2009,' Stk., CA 45201 <br /> Applicant <br /> AMOUNT REMITTED RECEIVED BY <br /> DATE PERMIT N0. <br /> 10/82 500 <br /> EH 13-24 REV. 10182 <br /> 14-25 <br /> J - - <br />