|
�^3tm'" .. - - .,> ..-•."`�'Ft fd't-" . - '^Yi?�Rfie , �?3".�'SN�"5�. _•,:.:5?Ma .:A ._
<br /> ' AFzPLiCATiON Pon PlaR IlT
<br /> r bAN JtiAdUIN`LC CAU NI�ALT l)l§tA1C
<br /> 1eni HAZ�LTOIAVT:® 9Td-�'fk CA`:
<br /> , ,0,0
<br /> Ippon 10916 6781 'E
<br /> >,t, IgE i It XpIR�5" ' DEAF# �#OM_DO ISSIi(`D, Y4,
<br /> � 1Coriipit3 a In,Tdplicat
<br /> Application is hereby bade to the fan Joaquln Local Health District-for a permit to construct and/ohnstall the work herein described:-thla`aflplit6"aflon is
<br /> made in compliance with San Joaquin County Ordinance No.549,for sewage at No 1862 for Weil/pump and the Rules and Regulations frl that Sag Joaquin
<br /> Local Health District. "
<br /> , Se u '*
<br /> a*
<br /> �
<br /> t � �, � •. � �
<br /> Job Address �renC{tCmO" j andfill l City °. �OCIC�On Lot Sizo PM
<br /> a,
<br /> Xowners Name Ctof Stockton Address 425 Northl:�." Dor�dOT` =Phone 209-944-8339'
<br /> (�1E1 ru` I-a�Y
<br /> EMCON NssociateS Address 1921 R nawood live, San J4. nse No. 'none 408.2 5-144
<br /> (Contractor ,
<br /> TYPE OF WELL/PUMP:,,,,. �, NEW WELL O WELL REPLACEMENT O $, Z DESTRUCTION © ���"
<br /> PUMP lNS1 ALLATION O SYSTEM REPAIR O OTHER l�/' t
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPGSAI:I�Lb. 50 PROP.'LINE 2 M>~1`
<br /> FOUNDATION "' AGRICULTURE WELL ">T15l'H5R WELL;" 5 PITS/§UMPS *
<br /> INTENDED USE TYPE OF WELL ` :, PII0BLEM AREA CONSTRUCTION SPtCIEICA'tI6N5
<br /> C1 Industrial C� Open Bottom �d Manteca,, Dia. of Well ExcavatioN'�'n°� " Gia. of Well Casing z'11
<br /> ,
<br /> ❑ Domestic/Private dt Gravel Pack 0 Tracy `type of Caslnd-schedule' I��li' 5pbcificafionS
<br /> ,'
<br /> Cement/5% be t
<br /> l't Public C1 Other.,.��� `" � �' ' � Delta"'. �` Depth of Grout Siial 45 '- .'type of Grout �.
<br /> I I irrigations �-RlApptox. Depth i I Eastern SuNace Seal installed by �t' •1"Llti EX" 1,� bra+ r
<br /> Repair Work Done , U <type of Pump H.P. State,i�/otk Done� '
<br /> Well Destruction 0 Well Diameter Sealing Material (top 50'1
<br /> Depth Pilfer Material l8elow 50'1 l �1
<br /> TYPE
<br /> OF SEPTIC WORK:, NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1 DESTRUCTIO i I INo septic system permitted if public sewer is
<br /> >' aysifable within 200 feet.1
<br /> installation will serve: Residence Commercial __: Othar "
<br /> Number of living units: Number of bedrooms s *'
<br /> Character of Soil td i depth of 3 feet: t . p
<br /> Water table de th �
<br /> SEPTIC TANK ° :0 'Type/Mfg Ca city No. Compattr»ents '
<br /> PKG..TREAtMENt PLT,d �4 Method of Disposal t
<br /> Distance to nearest:
<br /> Well P ndat PFoparty Line y
<br /> t ,y ,
<br /> x
<br /> F S
<br /> LEACHING LINE ❑ No. &Length of lines total lengfh/slid :y
<br /> t 3
<br /> FILTER BED t]," Distance to nearest Foundation Prrperty Line
<br /> �. ,.
<br /> SEEPAGE PITS I I ' Depth' Siza Number
<br /> SUMPS L7 '
<br /> Distance to nearest: W Foundation Prof, y Line
<br /> DISPOSAL PONDS Cl'
<br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin PoUnty,+ordinances, state laws, and
<br /> rules and regulations of the San Joaquin Local Health District.
<br /> Nome owner or licensed agent's signature certifies the following: "1 certify that In the performance of the work for which this permit Is issued, I shall not
<br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring br sub-contracting signatureilF
<br /> certifies the following:"I certify that in the performance of the work for which this permit It issued,I shall Employ persons subject to workman's compensa ;
<br /> tion laws of California." k v g
<br /> The appli nt mus call ( aIt required i s ctlon§. Complete%drawing on reverse gide.
<br /> �igned title: V'e1_. bate..
<br /> FO bEpARTMENt USE ONLY
<br /> # ,
<br /> Appiica Accepted by Data
<br /> x
<br /> Date
<br /> Pit o' Grout spection by fiats I F}\final Itifipaction by
<br /> ip-\
<br /> -:w`4J> ��'` q 3k�
<br /> Additional Comments: r
<br /> O Stk 466-6781 d Lodi 3621 O Manteca823-7104 O Tracy 835-6385 `s a dna
<br /> Applicant- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P O..Soit 2009, StkCA 9520f
<br /> FEE AMOtJ1Ut DUE AMOUNT Amino D SH RECEIVED tlY (TATE ' ` PERMIT'No. 41
<br /> INFO 1.0
<br /> x EH t3.241REV,I/As)
<br /> EN i42e � 7 ,
<br />
|