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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT UPIRAS I YEAR PROM DATE SSUED (Complete in Triplicate) Application is hereby made,to Sam Joaquin County 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 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Bird Rd. , South side Job Address 5404 Durham Ferry Rd. .3mi. west of city_ Tracy_ _ _ Lot Site/Acreage 2 acres Owner's Name Targowski Construction -Address 27743 S. Corral Hol low, Trac Phone 835-2786 Contractor Hennings Bros. Address 3525 Pelandale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP. NEW WELL N WELL REPLACEMENT P DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ 1001 SEWER LINES DISPOSAL FLD. 100' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of Well Casing 6 11 (X Domestic/Private 00 Gravel Pack P1 Tracy Type of Casing PVC Specifications 160 M Public 1-1 Other ❑ Delta Depth of Grout Seal 000,_____ Type of Grout Bentonite Ci IrrigationIMApprox. Depth ❑ Eastern Surface Soul Installed by dri i j Ar --_ Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Welt Diameter Sealing Material 4 Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION Cl DESTRUCTION GI (No septic system permined if 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,Q Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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, statelaws, rules and regulations of the San Joaquin County 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 env person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub contracting signaturPe 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 onrse side, Signed X__Hennings.,,B,rBY Title: R Date: 4--17-91 F DEPARTM USE ONLY Q Application Accepted by Date ` Area Pit or Grout inspection by Date Final Inspection by P'"' Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 8520.1 FEEINFO AMOUNT DUE AMOUNT REMITTED CK fiECEIVfD BY DATE PEAM17'NO. . FH13.24IAFV.k/NSl �Q -.C,-> 'U L" '`� •®� q + . f:,�3 ICU{ ICUl l` 1