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APPLICATION FOR PERMIT -��-- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 112091 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. Carter Rd. Lot #1 )Qp � 207-060-157I. Job Address City Lot Size PM Owner's Name Villa Development Inc. Address 32552 S. Bird Rd. , Tracy Phone 832-2322 Contractor Hennings Bros. Address 3525 Pelandale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1211 u ❑ Industrial LJ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing 6 X(Domestic/Private )()(Gravel Pack )(X Tracy Type of Casing PVC i Specifications nPublic ❑ Other F] Delta Depth of Grout Seal Type of Grout Bentonite + I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by driller Repair Work Done L7 Type of Pump H.P. State Work Done_ 1 Well Destruction ❑ WeII Diameter Sealing Material (top 501 6 - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l I DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence Commercial_ Other Number of living whits: Number of bedrooms Character of soil to'a depth of 3 feet: Water table depth SEPTIC TANK 's ❑ Type/Mfg - Capacity No. Compartments E PKG. TREATMENT PLT: ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � X 'SEEPAGE PITS [ I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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. t 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 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on r erse side. Signed x Title Date: 11-20-90 FOR DE RTMENT USE ONLY + Application Accepted by ADate Area / Pit or Grout Inspection by �' � i Date C Final Inspec 'on by Date >> Additional Comments: .s' © Stk 466-6781 ❑ Lodi 369.3621 ❑ f4lanteca 323-7104 El Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 TREY,t/n 5f � i !(3 ,�- /�'�7�V/$� /g -3 J EH 14-28 �o`L(/�`� —ems- j �