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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT pAyE vE� 1601 E. HAZEL T ON AVE., STOCKTON, CA RSG Telephone (209) 466-6781 113 �9 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP (Complete in Triplicate) _��pp�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hE<rA7klrO�l � ion is made in compliance with San Joaquin County Ordinance No:549 for sewage or No. 1862 for well/pump and the Rules and Reg �rtlhe San Joaquin Local Health District. Job Address 4820 W. Durham Ferr Rd . City Tracy Lot Size PM Owner's Name Tar owski Const. Address 27743 S. C rral Hol law Rd -Phone 835-2786 Contractor Address '4525 PPI ante 1 P. Ay __- Od._icense No.x_0.8_.,.3—Phone 545– I 1895 TYPE OF WELL/PUMP: NEW WELL)U( WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 �][� I SEWER LINES 100�_._ _, DISPOSAL FLD. 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 Dia. of Well Casing u "Domestic/Private DO Gravel Pack Ix Tracy Type of Casing P V C Specifications I'1 Public C1 Other F1 Delta Depth of Grout Seal - 1 0-02.— Type of Grout B P n t o n i t e._ I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Hennings Bros . _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION [ I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 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 0 No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line T SEEPAGE PITS I 1 Depth Size Number IP leg SUMPS Ll Distance to nearest: Well Foundation Property Line� DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cbu rdi ances, state laws, ander 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 Ash�311`ttZST employ any person in such manner as to become subject to workman's compensation laws of California." Contractort;A ZS {{�tslignature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons su�'+Ivbrkman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on,revarse side. Signed &V nM hV �,I_u-, I iNe: Date:14 QJFOR DEPARTMENT USE ONLY Application Accepted by Date Area 7 Pit or rout spection by Date�a/�� I Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K 10 INFO RECEIVED BY DATE PERMIT NO. *,EH 14-24(REV.tik51 es�1� r / EH 14-26 �L �d� �S '^7