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te A4 r APPLICATION FOR PERMITIk �� ! p 1, .. SAN JOAO.UtN LOCAL HEALTH DISTRICT J 1601 E. HAZE i ON AVE., STOCKTON, CAFH Telephone 1209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRO!ViENTAL HEALTH (Complete in Triplicate) ERj1jl /SERVICES 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. Job Address 152 EAST 11TH STREET City TRACY Lot Size 8 5 X 10 6 pM _ Owner's Name. A- NAVARRA Address 475 WEST BLEWETT ROAD, TRACY Phone 83 6-0005 (209 ) , Contractor SIERRA DRILLINGAddress 2220 JEAN INC DR. , MODESTQense No. 521617 Phone 578-9900 I TYPE OF WELL/PUMP: NEW WELL PS., WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 2-'/06A+ DISTANCE TO NEAREST: SEPTIC TANK _._:.__"SEWER LINES 30 FT DISPOSAL FLD. PROP. LINE 5 FT FOUNDATION 15 FTAGRICULTURE WELL OTHER WELL 50 FT PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 .5 IN Dia. of Well Casing 2 IN. # HCl Domestic/Private (XGravel Pack - X Tracy Type of Casing 1±480 PVC Specifications M 1 �ITORING _ �J ub is ❑ Other I Delta Depth of Grout Sea! 8 FT Type of Grout CEMENT Ir I Irrigation _--Approx. Depth 1 I Eastern Surface Seal Installed by SIERRA DRILLING _ Repair Work Done ❑ Type of Pump H.P. . State Work Done_ + Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIWADDITION{ 1 DESTRUCTION l I (No septic system permitted if public sewer is r available within 200 feet) - Installation will serve: Residence Commercial Other- Number therNumber of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size l FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI 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, 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicat ust c f r 11 required inspections. Complete drawing on reverse side. Signed X Title:- _OVAMSR�nuc,r.rwr•r• Date: 1-c'EM IAR?Y 2 2 1 9 8 8 �i. R EPARTMENT USE ONLY ` Application Accepted bydate Are i Pit rGroutI spection by dates' ' f=inal Inspection by Date L�o� 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. Bax 2009, Stk., CA 95201 FEE INFO AMOUNTDUE AM�jOUNT T REMITTED CK RECEIVED BY DATE PERMINO. ♦ EH 13-24{REV.v/K 51 ?'CL .N \ EH 14-26 I r`