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Y .� APPLICATION FOR PERMIT : ,p SAN JOAQUIN LOCAL HEALTH DISTRICT g • ( � }� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 vl PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 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 29360 BIRD RD., City TRACY Lot Size PM Owner's Name DO MQ C O N SL Address 8 9 61 A! M F N!n R A TRACY Phone 835-2922 Contractor H F N N I N G S R R 0 S - n R T)_Address 3 5 2 5�5P F I A N D A I F A V F License No. 2 9 Q J_3 Phone TYPE OF WELL/PUMP:. NEW WELL 00 WELL REPLACEMENT ❑ DESTRUCTION P.UMP INSTALLATION ❑ SYSTEM.REPAIR ❑, Z-- OTHER ❑, DISTANCE TO NEAREST: SEPTIC TANK 1-00a + SEWER LINES A 00 r + DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS h ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation 2 tt Dia. of Well Casing IE Momestic/Private Q(Gravel Pack )()(Tracy Type of Casing -QVC Specifications Fl Public n Other ❑ Delta Depth of Grout Seal Type of Grout-13-U TO N i T F I Irrigation ---Approx. Depth I ]'Eastern Surface Seal Installed by H F N N I N G S R R Q S -0- 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 REPAIR/ADDITION i l DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:'ZResidence' : Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth'of-3.feet: Water table depth ,Q SEPTIC TANK ❑ Type/Mfg Capacity J No. Compartments r PKG..TREATMENT PLT. ❑ q ? 4 „ 1 r _, _ f{ i��i: I: �t a f Method,of,)Disposal Distance to nearest: Weil Foundation Property Line LEACHING LINE ❑ No, ✓?,'Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1.1 Depth s Size Number r! - - i yr---- — --- SUMPS ❑ 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, 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 call for all required inspections. Complete drawing on reverse side. a Signed -�� t}e': Date: AOR DEPARTMENT USE ONLY { Application Accepted I Dat `— Pit or rou nspection b ri� Date Final Inspection.b D Date�'��— Additional Comments: u C /S "046 /?orf MA y tAg�or,•c%^— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.Hazelton Ave., P.O. BoER"6h 95201 rq��HE"LT ,.. PRM,, INFO CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE P IT'NO. . EH13-24 IREV-i/n 51 /�yy � } EH 14-26'.:- -Q. n;d 0f 9 � 1