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ws J. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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. I Job Address 19486 Corral Hollow Rd . City Tracy Lot Size PM Owner's Name Sam Corso 19486 Corral Hollow, Trac 835-6938 Address y Phone k Contractor's Name License No. 290813 Phone 5 4 5– 1 1 8 5 TYPE OF WELL/PUMP: - NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - 10 0 ' SEWER LINES DISPOSAL FLD. 10 0 ! PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11 1 Dia. of Well Casing 6 11 DX Domestic/Private EX Gravel Pack )C](Tracy Type of Casing PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 501 p Type of Grout Bentonite __Q ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by d r i I 1 e r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 61 Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) i Installation will serve: Residence— Commercial_ Other Q Number of living units: Number of bedrooms i —� Character of soil to a depth of 3 feet:' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size O ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line { 1 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 Q_ 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."Contractors 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 parsons subject to workman's compensa- tion laws of California." %Y' 773 Z/ ' The applicant must call for all requir inspections. Co plete drawing on reverse side 119 Signed Title: Date: 5-25-84 I �_ f OR DEPARTMENT USE ONLY g Application Accepted by �-�`" Date Area V c Pit or Grout Inspection by Pate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 ❑ Tracy 835-WW Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.70/83) q 19i�1_4 EH 14 26 C_`?C? �Z�4i a �Z / �C{p7