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+ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA ✓ I Telephone (209) 466-6781 / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) the San Joaquin Local Health District for a permit to construct andlor install the work herein described. Application is hereby made to cThis 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. ii 15420 HWY. 4 City Lot Size PM Job Address 1 ALDO TOGN I NAL I Address 14500 E . HWY 4 , STOGMN Phone 94 — Owner's Name 't Address I License No. Phone ContractorING DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT lei. OTHER 0_ PUMP INSTALLATION ❑ y SYSTEM REPAIR ❑ DISPOSAL FLD. PROP. LINE � DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL�JOTHER WELL PITSISUMPS ` FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing all— El Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Type of Casing Specifications EX Domestic/Private Gravel Pack ❑ Tracy t Depth of Grout Seal Q Type of Grout ��_I.T-E— I I Public ❑ Other Delta - irrigation _Approx. Depth i I Eastern Surface Seal installed by H E N N I N G SRQ -�__. I L��_ H P State Work Done Repair Work Done ❑ Type of Pump — Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Depth Filler Material IBelow 50'1 k TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t I DESTRUCTION I I (Noavas Attic systithinem feet.) if public sewer is f Installation will serve: Residence Commercial_ Other Number of"living units: Number of bedrooms t Water table depth Character of soil to a depth of 3 feet: f . Capacity No, Compartments SEPTIC TANK ❑ Type/Mfg [ Method of Disposal PKG, TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line f LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number-'F _ - ---a=� — — "— —SUMPS-"—y` i" "� Ll Distance to nearest:—Well Foundation l� - Property Line r DISPOSAL PONDS ❑ 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. ify that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signature certifies the following: "I cert r 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 shalt employ persons subject to workman's compensa- I tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. i Signed X Title: �c�1f'� ��' Date: b R DEPARTMENT USE ONLY �fo # Date �^ Area—2-&— ` Application Accepted by t, d G Pit or Grout Inspection by S T(lz Date d Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2069, Silk., CA 95201 FEE AMOUNT!DUE AMOUN=REMITTEDCASH RECEIVED 6Y DATE PERMITNO. INFOEH13-241REV.t/N51 q0-1 EH 14-28