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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 P PERMIT EXPIRES 1 YEAR FROM DATE ISSLR& E[yEp (Complete in Triplicate) ff;; . 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install work 919a described. This application is made in compliance with San Joaquin County,Ordinance No. 549 for sewage or No. 1862 for well ljgtif{lp lnnd the Rules and Regulations of the San Joaquin Local Health District. ��vv�t NAIEN PEP'"T/S�W E ALr" Job Address . 5925 Durham Eerry Rd. _'City Trate +G Lot Size ��SCres PM Owner's Name Joe Saen7 Address 1434 Mad S n Ave. Tracy Phone – 2796 Contractor_ nings Bros. Address 3525 Pelandale, Mod. License No. 298813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 0001__.. SEWER LINES 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 1211 Dia. of Well Casing 611 l Domestic/Private )o Gravel Pack Q(Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal 1.001 Type of Grout IRcntnni'tP _ f I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by driller „ Repair Work Done ❑ Type of Pump H.P. State Work Done _ [/�I Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ( n 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 C PKG- TREATMENT PLT. ❑ Method of Disposal �p Distance to nearest: Well Foundation Property Line Q�c� LEACHING LINE ❑ No. 81 Length of lines Total length/size 3 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number Ti SUMPS ❑ Distance to nearest: Well Foundation Property Line 'k) 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 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 to workman's compensa- tion laws of California." The applicant must tali for all required inspections. Complete drawing on revers ide. Signed X uennngs--BroS Title: R, g 00 Date: 8-17-89 - FDEPARTMENT SE ONLY Application Accepted by Date , Area Pit or Grout Inspection by Date Final Inspection by to 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 %r- Hos,-. e s/n(,�o.,,.ed• Aw. smi# ,- ,O.K 4Z7 FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERM{T . INFO +.EH 13-24 IREV.I/H 5] O 23q S -7-I EH 14-28