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- — - _•_ - __• - - - ..__ _-__ ._ - --T.. nom..- ;.'• r. —._ _..-_'a.��-_. .f � _. _.��_ r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT D FS 036- 1601 E. HAZETON AVE., STOCKTON, CA R-7- Telephone !209) 466-6781 p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED or 4004c,- A{wit�1 I (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District- S-y�q f N. Job Address SCAL-ON - &ELL 07-A• Pct}Q �'e`r!olcity LINbcA1 Lot Size q0D A-r-- PM Owner's Name FOSTE P_ tJ IZR-f Fl" Address !000 DAVIS ST_, L wI N 6SIZ O 0A. Phone l- '40 6$ 1 �;'� L'.i'�►A��ti?•R"i 1-gyp „tee Contractor DW hl Address i License No, Phone .TYPE OF WELL/PUMP: T y, NEW WELL;❑ WELL'REPLACEMENTA0 +--DESTRUCTIONPO «�... w,..�.=,ft. 1W � rPUMP INSTALLATION ❑ ` SYSTEM REPAIR [Ji �+OTHER ❑-� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T 1 FOUNDATION AGRICULTURE WELL OTHER WELL'M'At%ePITS/SUMPS T V INTENDED USE TYPE OF WELL PROBLEM AREA 'NST CORUCTION SPECIFICATIONS ❑ Industrial t 71 Open Bottom ❑ Manteca°�'"" ia. of Well Excavation -"�� r Dia:of WeU Casing • ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing s ji, _Specifications ' 1`I Public Cl Other �1❑�Oelta 0 +ft_,. epth of Grout Seale " ;Type of Grout ` I 1 Irrigation{ Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. 04 R State Work Done _ Well Destruetiton ❑ Weil Diameter 'Sll. ealing Material stop 5a'l; ^� Depth Filler Material (Below 50') TYPE.OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1.1 DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.1' ' Installation will serve: Residence__L_ Commercial— Other A +Number of living units: N tuber of be Fro9ms/ " } Character of soil to a depth of 3 feet: .. /1 n fie llt I Water table depth l 2� SEPTIC TANK T ) ype/M fg Capacity 1700. - No. Compartments Z ` PKG. TREATMENT PLT. ❑ ! Method of osal } like T r- Distance to nearest: Well 0 Foundation ..-I- DispI - ! � k LEACHING LINE No. & Length of lines 0 Jf Total length/size +•^�- FILTER BED ❑ Distance to nearest: Well 2 OD Foundation Prop arty Line-57d SEEPAGE PITS I I Depth Size «}'�_ - _ Number SUMPS Cl Distance to nearest•. Well Foundation,, 1 Property Line DISPOSAL PONDS ❑ rnI �, `�► . »` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home-owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa l tion'laws of California."t },�� TIF 3 1 wr y d s . The applicant must cOa1'1 for all required inspections. Complete drawing on reverse side. Signed �A / Title: �wn�.� Date:" U-16- t l'�— " it� 'SN I\A tv► FORDEPARTiNEfVT USE O %JN NLYA '9eklo�C'1 I ation Accepted I c�T� Date Area Pit Grout Inspection by Date ZFinal Inspection bJ �A 1-20 � ate \ Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 •. i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 00, INFO AMOUNT DUE AMOUN�T�REMITTED K RECEIVED BY DATE PERMIT'NO. r EH 13-24(REV.I/N5) �,// EH 14-26