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46 V7 APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT L G ? i 1601 E. HAZELTON AVE., STOCKTON, CA; Telephone (209) 466-6781 _. iL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate} , Ip ' 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 6.. 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.` 1 Jab Address �a ��fn�/1 �1hy Ave r,� City � Lat Size :. Owner's Name aC'v' foods Address i7 v� S«+ �r�d1Q A�/e py�r 7iZ3 Phon� / Contra 6r T��1n Opp 1r Address 8&15 317 T1r.AS —^License No.373-65 Phonee-Z i TYPE Of,,WELLlPUMP: NEW -7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C7 SYSTEM�REfPAIrOSAL FLD. R El DISTANCE TO NEAREST: SEPTIC TANK SEVOER,eLI.NES� � DISPbt y�tf f OP LINE MW3 FOUNDATION Z- 14 r AGRICULTURE WELL + OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS Z �/ ` ❑ Industrial -.., . 411-MIM Open Bottom ❑ M.Tnteoa Dia. of WeN'�-Excav t`i°�n""- Dia. of Well Casing ❑ Domestic/Private ❑ GravelaP.aCk a i Tracy Type of Casing v Specifications ❑ Public ❑ Other G Delta Depth of Grout Seal _ l _ ❑ Irrigation o Type of Grout &W 61 g pprox. Depth � y Eastern Surface Seal Installed by -� Repair Work Dane ❑ Typof Pump f" H.P. State Work Done Well destruction Weil..Diarnete Sealing MaterialMop 50'1 Ilrf W Deplh � _�" fil -ler Materia`I`I•Below 50'j"�" -� TYPE OF SE C WORK: NEW fNSTAL'LATION © REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system yy p' y permitted if public sewer is ' l f �„r available within 200 feet.) Installationwill server Residence_ Comrne�cial_ Other ro Number of living units: �N'ml rr..of°bedrooms= t Character of soil to a depth of 3 feet: f tt � Water table depth SEPTIC TANK ❑ ype Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Q Distance to nearest,# W el '"`�e Foundation� Property Line LEACHING LINE D No.& Lenngh of lines o- Total length/size FILTER:BED. .:. .�--T ❑ istance.tc -_eare_st: Well undation SEEPAGE PITS LlDe.tf� t � � Property Line � n -- �..,. - p h � SizeNtymber + SUMPS ��istance to nearest: Well Foundation_ Property Line 7 DISPOSAL1,7,0L S ❑ �Q a C� F I hereby certifytthat I have prepared this applicationtand that the work will IA done in accordart'ce 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 Ilia 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 performande of the work for which this permit is issu�, I shall employ persons subject to workman's compensa- tion laws of California." The applican u call for a 'n e i s. mplete drawing on rev'rse ' Signed Title: �w .5� Date: v"� `''�• FOR DEPARTMENT USE ONLY Application Accepted Date Pit or Grout Inspection by' e i y As n by ' Additional Comments: y ❑ 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 2009, Stk., CA 95201 - I FEE AMOUNT DUE AMOUNT REMITTED CCK-4V RECEIVED BY INFOH DATE ; 3]+ EH 13-24 REV.1/85Y EH 4-26IW .1