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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1:.YEAR FROM DATE ISSUED (Complete in Triplicate) Of 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. � i - Fornasero_Esta.tes Aprax-„ �- Job Address Lot #8 _ arie Ct City T r a m Lot Size 17 5 I X 2 5 0 t IpM Owner's Name 12 I t o D e V: Co- Address _a.x .7414 . StoC k t o n Phone –0343 Contractor Address 3 5 2 5 P e T a n rl;; 1 in M O-5-i_ License No._ _�9�3 Phone TYPE OF WELL/PUMP: NEW WELL [A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK 1001 SEWER LINES DISPOSAL FLD.1-00 I PROP, LINE 5 T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " _ Dia. of Well Casing " (Domestic/Private EX Gravel Pack Tracy Type of Casing Pf f:_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1601 Type of Grout Renton to t El Irrigation _-4pprox: Depth ❑ Eastern Surface Seal Installed by V� Repair Work Done ❑ Type of Pump H.P. State Work Done } i Well Destruction El Well Diameter Sealing Material (top 501 ;. Depth Filler Material (Below 501 TY-PE-OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will se sidence_ .,,Commercial_ Other Number of lining units: of bedrooms } Character of soil to a depth of.3 feet{ Water table depth T SEPTIC TANK .❑ Type/Mfg Capacity No. Compartments 11 l PKG. TREATMENT PLT. ❑ j Method,of.Disposal `. Distance to nearest: Well Foundation Property Line p t + LEACHING LINE ❑ No. & Length of,li nes - Total length/size FILTER BED ❑ Distance to nearest: _ .Well Foundation Property Line t SEEPAGE PITS E) Depth Size Number SUMPS 1:1Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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- tion laws of California." The applicant must call for all required inspections. Complete drawing on revy5se si e. Signed - Title: r Date: 10-20-87 .�- FOR DEPARTMENT US NLY Application Accepted by 'ti _ Date =Area �15_ Pit or Grout Inspection by Date 10- Final Inspection by -� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE � INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + Er113-24IREV.1i85) �p � �`7�fS /�Z-F? P?._3cl�� Ex 14-20 E