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i 46" APPLICATION FOR PERMIT " Li SAN JOAQUIN LOCAL HEALTH DISTRICTN 1 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 :,_`x.) N 1`:�Q f V-! LOCAL ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '!LALT9- IMSTRIGT (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 19889 Patteson Pass Rd. city' Tracy Lot size PM Owner's Name Arnold David Address 19889 Patterson Pass IrD-f-yphone Rennin s Bros . 290813 Phone - Contractor's Name g License No. 1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP.INSTALLATION ❑ SYSTEM,REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK- ~� SEWER"LINES ' DISPOSAL�FL-D.• - :PROP. LINE FOUNDATION AGRICULTURE WELL `ry' OTHER WELL-30- - PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it E3 Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing HOomestic/Private A Gravel Pack' UTracy Type of Casing PVD Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50 , Type of Grout BentOn UP .❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by d r i 1 ler Repair Work Done ❑ Type of Pump l H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 501 Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 Disposaly,� Distance to nearest: Well Foundation Property Line �l r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line 'l SEEPAGE'PITS -❑ Depth.----4L=- -- -Size- -' - - -Number,. - ----- _ SUMPS ❑ Distance to nearest: Well Foundation Property Line O 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 1ssued,'I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature ' certifies the following:"l certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion ompensation laws of California." ! x The applicant must call for all required inspections. Complete drawing on r arse side. ennin s Bros . D.ri 11 in CO. Date: 6-90-S2Q . Signed A Dt ' OR DEPARTMENT ONLY Application Accepted by Date $ Area � kl Pit or Grout Inspection by Date. Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1 ❑ Manteca 823-7104 ❑ Tray 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE k� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO "~ + EH 1324IREV. 10!831gn� ' EH 14-28 - ��