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ry l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA mr- NT Telephone 12091 466-6781 1' �' PERMIT EXPIRES 'I'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 applica iiN�'tii�{ made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulation gt�,,trseAL in Local Health District. t�N� 1 �1C S I.�ZIv� 1 Job Address 18777 S. Tom Paine Ave: city Tracy Lot Size PM Owner's Name Don CO5e & ASsociates Address P.O. BOX 326, Tracy Phone 836-0422 Contractor_Hennings Bros. _ _Address 3525 Pelandale, _Mod. License No. 290813 Phone 545-1185 OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1 SYSTEM REPAIR ❑ OTHER ❑ j of— w-s cur DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD. 100' PROP. LINE - R � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation lilt Dia. of Well Casing fin (Domestic/Private };Gravel Pack XX Tracy Type of Casing Specifications (`l Public f 1 0�er {] Delta Depth of Grout Seal 4401 Type of Grout-BeatC itE I I Irrigation }C Approx. Depth i I Eastern Surface Seal Installed by dr i _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 S TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 111No 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to neatest: 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, 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 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 rse side Signed Title: Date: 4-28-88 FOR DEPAfi ENT USE ONLY Application Accepted by ` Date Area n — ,�7 �� Pit or Grout Inspection by Date? Final Inspection by Z Date 7 1 Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE y��Ay/,M,O�UyNT REMITTED C SR�y RECEIVED BY DATE PERMIT'NO. +.EH(321[REV. /n 51 'C /0 - EH 10-26 VVV V