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1! APPLICATION FOR PERMIT �v SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE; TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 descrikThis iion..is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for well/pump and the Rules and Reuulations of the Sa qui Local Health District. ; I Job Address 29360 SrRD RD., city T R ACY Lot Size PM Owner's Name D 0 i,Ly,l.-_S',_DRS T_ _ Address Aq 9 6 1D R.A T P A rY- _ Phone 835-2922 Contractor H F N N F N(a S__R P,n S_ 111?T_ Il 1?T Address ,License No.—2-90_$_Q_..._Phone_ 54 S-14-815- TYPE OF WELL/PUMP: NEW WELL DO WELL REPLACEMENT ❑ DESTRUCTION L-} PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK . 100 "+ SEWER LINES ,-00 f 4— DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial Cl Open Bottom L) Manteca Dia. of Well Excavation T 2�° _ pia. of Well Casing XXIDomesticlPrivate Q(Gravel Pack (Tracy Type of Casing PVC Specifications I'I Public Cl Other 1-1 Delta Depth of Grout Seal --I Type of Grout_B-BTUITT-E.. I I Irrigation _ Approx. Depth I I Eastern Surface Sual Installed by-..-HN r M GS BRQ S —DRIULNG CO- Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction C7 Well Diameter Seating Material Itop 50') Depth Filler Material (Below 501 _ 91 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION I I INo septic stem ennittud it P system p public sewer is i 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 LI Type/Mfg Capacity No. Compartments �r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE 1-1 No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line II SEEPAGE PITS I I Depth Size Number kF SUMPS 1-1 Distance to nearest: Well Foundation Property Line 4 DISPOSAL PONDS L.1 L 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 1 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.[, Signed X �C N� 1" fe:� �"�� .`� p Date: ? FOR DEPARTMENT USE ONLY `� c Application Accepted by Date✓— JD Pit ar rou nspection by Date �2 �� R E C�J V Gr Final Inspection by E Date Additional Comments: �� L7 Silk 466-6781 Oro CI Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j ,ren Q f Applicant - Return all copies to: Environmental Health 'Permit/Services 1601 E. Hazelton Ave., P.O. Bo' gip ft(Xrf'� ,moo I NTAL HFq r�i FFEAMOUNT DUE AMOUNT REMITTED CK EaRECEIVEDYINFO CASHDATE P IT'NO. + EH la'241REV.t,Kgi