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r APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT tZIG <br /> I 1601 E. HAZEL T ON AVE., STOCKTON, -CAP��ND15 pts <br /> I Telephone (209) 466-6781 \A. D <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU NOile PP�o\- <br /> (Complete in Triplicate) �%4)0V,0tApplication is hereby made to the San Joaquin Local Health District for a permit to construct aninstall temork herein described. This application is <br /> 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 <br /> Local Health District. <br /> Job Address 152 EAST 1 1 TH STREET City TRACY Lot Size 8 9X9 7 PM <br /> Owner's Name AL NAVARRA Address 475 WEST BLEWETT ROAD Phone (2 0 9 ) 836-0005 <br /> (209 ) , . <br /> t <br /> Contractor SIERRA DRILLING Address P.O. 13OX 4931 MODESTO License No. 52161;7 Phone_5_78-9900 <br /> TYPE OF WELL/PUMP: NEW WELL k WELL REPLACEMENT ❑ DESTRUCTION 'O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ""DISTANCE TO NEAFhEST:'SEPTIC TANK"" '"t SEWER LINESDISPOSAL FLD.­ rt'PROP. LINE' 5 <br /> FOUNDATION __1_0_ AGRICULTURE WELL OTHER WELL 45 PITS/SUMPS <br /> j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial" ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8testi Dia. of Well Casing <br /> ❑ DDornesticlPrivate 2S Gravel Pack Tracy Type of Casing F480 PA FC- Specifications <br /> r Pirblitl RING ( } Other Cl Delta Depth of Grout Seal Fir Type of Grout CEMER" _ <br /> 1 I I Irrigation -Approx. Depth l I Eastern Surface Seal Installed"by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Weli Destruction ❑ Well Diameter Sealing Material (top 501 <br /> { Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION [.I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> # Installation will serve: Residence-- Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to-nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line (� <br /> . -- SEEPAGE"PITS- I I:.:Depth Size Number _ <br /> SUMPS Cl Distance to nearest: Well "Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> t 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> Y' 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• IF <br /> tion laws of California." <br /> The app7TA2 <br /> st r-". aired inspections. Complete drawing on reverse side. y <br /> Signed 1r, Title: _ OwNER SIERRA DRILLING412t 17, 1988 <br /> ' FOR DEPARTMENT USE ONLY <br /> 11uApplication Accepted by Date J'- �-t✓ `1�r� _/ <br /> Pito Grou nspection b r ate ��7Final Inspection by <br /> F RMI ❑ EqI <br /> Additional Comments: TISEk Vir' , `� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE ^AMOUNT REMITTED K H RECEIVED BY DATE PERMIT"N0. <br /> ♦ EH 13-24 iREV.r/K 51 �t`-'�-' �J�"•�✓ �, �� ✓— <br /> EH 14-26 <br />