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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 i (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. 1 Job Address 21955 Corral Hollow Rd. — City Tracy Lot Size PM Erceg Corral Hollow RealtyMike Owner's Name Address _ 1486 W. 11th Tracy Phone 836-0890 Contractor Address 3525 Pelandale, Mod. License No. 29081 3 Phone 545–1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONXX PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ =- `"^"""" "INTENT ED`USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ['1 Public n Other F l Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth 1.1 Eastern Surface Seal installed by Repair Work Dcne ❑ Type of Pump H.P. State Work Done ` Well Destruction IN Well Diameter 411 Sealing Material Itop 50'1 Rent-on i to r1P 1 I Pt¢ i Depth �9 Filler Material (Below 50') Rp_rito ite, ppllets /1► TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is ` lvt Ll } 11, Installation will serve: Residence_ Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms j 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 i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LZ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ I hereby certify thatl-have prepared this application and that the work will be done'in accordance with San Jdaquin county ordinances, state flaws, 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 taws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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 n reverse si Signed x�e[m-i cLs Bros. By. Titl Date: 4-24--91 j DEP TMENT USE ONLY Application Accepted by A Date 5 / Area / Pit or Grout Inspection by D e_.Final Inspection by Date fo 76 Additional Comments: c. 2 f ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 83616385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE CK.9I r tS INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I +.EH14-281REV.tins) �f}V S•� ~�� 13-24 f/� r