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' APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT ~ T 1601 E. HAZEL T ON AVE., STOCKTON, CA R G JV � r v` Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) H�p,LTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the-Mn0 J� r>� plication is `��1"+`� PPnnt {ilia an Joaquin made in compliance with San,Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the R n Local Health District. r' Job Address J 3792 S Ai rd Rd. city Tracy Lot Size PM Owner's Name _ Ray Targowski ConstructAWAs. 277.43 S. Corral Hollow, TracL Phone 835-2786— Contractor 5-2Contractor Hennin s BroS.. Address 3525 Pelandale Mod. License No. 290813 Phone545- 185' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ A PUMP INSTALLATION 11 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK logi SEWER LINES DISPOSAL FLD. 100' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation�. 1 Dia. of Well Casing 1 Domestic/Private X] Gravel Pack ] Tracy Type of Casing PVA_ Specifications r Public n Other F] Delta Depth of Grout Seal t Type of Grout-B-ed1i e--_— I I Irrigation Approx. Depth I J Eastern Surface Seal Installed by driller - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Fillet Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (l REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: 3 Residence_ Commercial_ Other m Number of living units: Number of bedrooms x h Character of soil to a depth of,3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r.r Method of Disposal a Distance to nearest: .. Well Foundation PropertV.Line LEACHING LINE D. No. & Length of lines _ Total length/size E FILTER BED ❑ Distance to nearest:" ' Weil Foundation " " Property Line SEEPAGE PITS I I' Depth Sire Number SUMPSCl Distance to nearest: Weil Foundation s Property Line r-... . _ - 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 Di§trict. 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 ust call for all required in ctions. Complete yawing on re rsei e. , Signed X L Date: 10--4-88 _ � OR PARTMENT USE ONLY — Application Accepted by-' � Date Z(9— Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comment: r-7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sika; CA 95201 r k FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24 4REV.r n 51 EH 14-2e Vk