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APPLICATION FOR PERMIT <br /> 1 , <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT ¢: <br /> r 1601 E. HAZELTON AVE., STOCKTON, CA ° <br /> I Telephone (209) 466-6781 <br /> ' f vt��Cr'y <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ter: , •. , <br /> (Complete in Triplicate) <br /> �} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This._applkation is <br /> 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 <br /> Local`Health Distnctm``-­ <br /> Tzst . ' Fornasero Estates A <br /> � rax <br /> Job Address L 0 t #1 p <br /> - - <br /> City 'T r cl cls.. Lot SizeI 1 PM <br /> Owner's Name —Delta D 2 V- C n Address �, R n x 7 4 14 S t <br /> 4: _ �y--.. .aC ki:-Q-Y] Phone <br /> Contractor Address ;I <br />- cense No.�R 1 '�Phone � <br /> TYPE OF WELL/PUMP: NEW WELL 0WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Q <br /> OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 1 SEWER LINES DISPOSAL FLD.JaQ I PROP. LINE -_,_�t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I III Dia.'of Well Casing it <br />` C�(Domesiic/Private i�Gravel Pack ? Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seat <br /> Type of Grout <br /> ❑ Irrigation ---Approx.'Depth ❑ Eastern Surface Seal lnstalle <br /> Repair Work Done ❑ Type of Pump WP State Work` e C_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth ; Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r <br /> # available within 200 feet.) <br /> n <br /> erve:�iesidence <br /> R Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:, Water table depth <br /> SEPTIC TANK ❑ Type/Mfg P Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method;of Disposal fff <br /> Distance to nearest: Well <br /> Foundatto Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length <br /> FILTER BED' ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ DepthSize Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin;Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on rev/erse side. <br /> Signed d e n Ti 111 S S r 0 S r, D V.Title: e Q <br /> Date10-20-27 <br /> : <br /> •. <br /> -+ ; FOR DEPARTMENT USE ONLY ]� <br /> Application Accepted by ; Date Area <br /> Pit or Grout Inspection by Date r R Inspection by Date <br /> Additional Comments: ; <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i{ <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> ` INFO CASH RECEIVED 6Y DATE PERMIT'N0. <br /> + EH 18-24(REV.1/65) �U `P f`1''? <br /> EH 1428 <br />