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�'` 4a00 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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. 1962 for weE/pump and the Rubs and Regulations of the San Joaquin Local Health District. Job Address /"o_ WetR4e • hip. _ City Vrac4c-r Site PM r Owner's Name �A&L; F6opz INC. Address N phos ['7tlet 6`tsJb Contractor Roy r Ivar rm-, bwe-- Address 1r3 W.Al*,ttK L. .,# irense No. i'h a4 76-153 TYPE OF WELL/PUMP: NEW WELL IIIA WELL REPLACE DE T1 p PUMP INSTALLATION © SYS R OTH DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS 1- ROP. LINE FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS 14 Industrial C Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private ❑ Gravel Pack ❑T ype of CasingC.Eel%.YD Specifications I.1 Public Pth____.d0EEr_ In Depth of Grout Seal Y r Type of Groutltaired-* tr 6 fj I I Irrigation Depth Surface Seal Ins Repair Work Done U s H.P. 41 S rk Done _Ne.+r Wen Destruction ❑ 41 Sealing Material.( d rye �1 r s l Glib Filler Material So') ,03 TYPE OF SEPTIC WORK: CATION I I REPAIR/ADDI I DESTRUC I 1 INo septicsys! tilted if public sewer is 7' h available wit ' tset.I Installation will serve: R `+Commercial_ OY. t ^ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Ar- Water table depth SEPTIC TANK 0 T '*" YpelMfg Capacity -" No. Can+psrtnlar►ts PKG. TREATMENT PLT.❑ Method of Disposal Distance to neareadWWell Foundation Property Lim LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Site Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C] I hereby certify that I have prepared this application and that the work will be dorm in accordance with San Joaquin coun"inances,state laws, and rubs and regulations of the San Joaquin Local Health District. Hone 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 shad not WnP10V MY person in such manner as to begone subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is rued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X446= �"' Title:_A-9-c r f t r PK o1 c c T_ FO t-e 614 TDate: FOR DEPARTMENT USE 9NLY I Application Accepted by �h,;� C..,k Date {fz�� Ana Pit or Grout Inspection by Date Fatal Inspection by Date Additional Comments: O Stk 4666-6781 ❑ Lodi 358-3821 ©Marden 923-7104 ❑Tracy 835.8395 Applicant- Return a6 copies to: EnvironrnantN N"th permit/Services 1601 E. Ha:shoe Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMiM0 INFO RECEIVED BY DATE pumm'No. •EH 174111 ntEv.1/a sl EN 14�! .,J? .f!?.+w_,•.,.'.'.s,_>`"�3alMs,"=< :.Y..1=:.�aLfi�F' [�9uilrLe�w.s� - -