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vn � r r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Y }' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address City Lot Size PM 9 Owner's Name dr�ssU n _ Phone `31— >A� t }.� ;a`l�c�nonl =7. Contractor Address_� o __License No. e TYPE /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP NK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08L EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca' f Well Excavation Dia. of Well Casing ❑ Domestic/Private :. ❑ Gravel Pack f- ❑ Tracy 7;, ---Type of Ca = F Specifications 4, ❑ Public ❑ Other 0--Delta F Depth of Grout Seal Type of Grout ❑ Irrigation " �_�Cpprox. Oepth' ❑ Eastern; -Surface Seal Installed by ! ' Repair Work Done ❑ Type of Pump ` M.P. State Work Done WellDestruction ❑ Well. Diameter Sealing Material (top 50'1 { d 1 Depth ' Filler Material (1409-501 �TYPF_OF-_SEP_JiCWORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION F1 (No septic system peribitted'if public sewer is J . t ` } I. ` available withiH 200 fb6t.) ?Lr �:� ate. :K.,, Installation•will serve:---Flex Ie mercial —?•flt r - /�0�� "�-Number of living units: �Nu (>f s-. r •� ( I °� eJ ,: r Character of soil to aiepth.of-3 feet -.- ' Water table depth r . r r r SEPTIC TANK --� 4ype/M g I Capacity:r*�_ �� N . Compartments { mow. Method of Disposal r PKG:TREATMENT PLT. ❑ � � � �1� -- �T 1 posal f k y Distance to nearest Well :� Foundation PropertyfLine,� +" - LEACHING LINE ❑ No. &'Length of lines Total length/siz111e r FILTER BED L ❑-�'Distance•tnearest: -Wi-----Foundation---Foundation Prop o Line SEEPAGE PITSepth Sizep�,��t Num¢er SUMPS Ll Distance to nearest: Well�s Foundation 0 j Property ine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa4binFcounty ordinances, state laws, and r. _.._- - �- .. _._ ,. ----r rules and regLlaibns of tie San�oagwn'Loca-Health nistrict. Home own r,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 5ny4beison in`such.manner as to. ecome subject to workrgan's 4compensation laws of California."Contractors hiring or sub-contracting signature certifies tl a c'1lowing:<l,cei-tify that inthe performance'_of' Gwbrk for iF,F4 hispermit is issued,I shall employ persons subject to workman's compensa tion laws of California V 1 The_applica ust cal for eq 'r d inspecppns., mpiete drawing_on.reveme side.— —--.�.�,r.. �,. j_ . or Signed—rteILdinelCood Title: Date: !__ FOR D PARTMENT USE ONLY' F. Application Accepted by S[+t/�z.c Date , Area Af Pit or Grout Inspection by ,( Date Date Final Inspection by py Additional Comments: /i eft;e A2, �/d ❑ Stk 466-6781 El Lodi 369361 ❑ Manteca 823-7104 ❑ Tracy 83x6385 �. �y 60 �` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2169, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO .p ' + EH 13-241REv-1/8516(920 EH 14-29 � b