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YA�4APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 workhereindescribed. 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 10935 W. Clover Rd. City Tracy Lot Size PM Owner's Name Frances Francesco Address 10935 W. Clover Tracy Phone835-4127 — Contractor Hennings Bros. Address 3525 Pel arida 1 e, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL XX WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 OO=L= SEWER LINES DISPOSAL FLD.A.0.0' PROP- LINE FOUNDATION AIGRiCULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^p. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12.11 Dia. of Well Casing 611 Domestic/Private UGravel_Pack XXTracy Type of Casing PVC Specifications _ f7 Public ❑ Other ❑ Delta Depth of Grout Seal 1001 Type of Grout RPn j]nl'h.P 1.1 Irrigation _Approx. Depth t I Eastern Surface Seal Installed by _ .-,(1 Repair Work Done ❑ Type of Pump H.P. State Work Done_ W ` Well Destruction ❑ Well Diameter Sealing Material Itop 50') { Depth Filler Material (Below 50') TYPE OF SEPTIC-WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:; �Reside.ncer Commercial_ Other Number of living units: Number of bedrooms Character of soil to.a depth of 3 feet: Water table depth_',�r T` SEPTIC TANK ❑ Type/Mfg Capacity—L— No. Compartments 4, PKG. TREATMENT PLT. ❑r, r..'+r: st Method.of'Disposal Distance to nearest: } Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines; Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F r SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line lblSPOSAL PONDS O` `'' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,' state lairs, and rules and regulations of the San Joaquin Local Health District. 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 10 workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawan 'evs Signed TitiLDate:FOR DET USE ONLY Application Accepted by Date Cl Area >/ Pit or Grout Inspection by Date Final Inspection by DateIff Additional Comments: AL- 4 S ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 . ❑ Tracy 835-6385 C allyrs Applicant - Return all copies to- Environmental Health Permit/Services 1601 E. Hazolton Ave„ P.O. Bax 2009, Stk., CA 95201 v�tc[5fFEE hG INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. a +.EH1 -241REV �3EH 14-28 0cx) fM