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�,��•---,.� -�. 1.,,..� tea -� r APPLICATION FOR PERMIT f _ J � SAN JOAQUIN LOCAL HEALTH DISTRICT �� • .Y yr-_' , 1601 E. HAZEL T ON 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 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 21760 S. Bird Rd. City Tracy Lot size 2321000 1 PM F Owner's Name t1.[). MOSt Const. Address 3941 Holly Dr.#A, Tracy Phone835-6921 Contractor Hennings Bras. Address 3525 Pelandale, M-Qds License No. .290813 Phone545-1 AS TYPE OF WELL/PUMP: - NEW WELL WELL REPLACEMENT.❑ DESTRUCTION ❑. K+-rHy PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK None SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6W EX Domestic/Private IC)(Gravel Pack Q Tracy Type of Casing PVC Specifications Fl Public EI Other ❑ Delta Depth of Grout Seal 100, Type of Grout...__Beriton i to_. I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by driller _ w Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line " hC LEACHING LINE ❑ No. & Length of lines Total length/size l� FILTER BED ❑ Distance to nearest: - Well Foundation Property Line � a SEEPAGE PITS i I depth Size _ Number-. - SUMPS L71 Distance to nearest:. Well Foundation Property Line 1 DISPOSAL PONDS ❑ 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 . ' a ents si nature certifies thefollowin g g g: "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." Contractoi'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 ail required inspections. Complete drawing o rseside Signed X 1 '� Title: Date: 6-26-89 FO DE fiTNkENTUSEONLY Application Accepted by Date y r4rea _ Pit or Grout Inspection by Date Final Inspection by Date d3 Additional Comments: _ �7 C'Cam �r rClr�u f-�v lav-1- El fY El Stk 466-6781 - ❑ Lodi 369-3621 UO Manteca -7104 6 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201FEE f INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. EH+"EH 13-24 MEV.t i K s) '�s �1r�O