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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA' Telephone (209) 466-6781 ' PERMIT EXPIRES 1-YEAR FROM DATE ISSUED l (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 C unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address 10820 W. Tracy Blvd. city Tracy Lot Size 204'X204' PM Owner's Name Gloria Baccnetti Address 10820 Tracy Blvd. , TracyPhone 835-1442 contractor Hennings. Bras. 1 Address 3525 Pelandaie, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ? DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 65 SEWER LINES DISPOSAL FLD. 65'+ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 331 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excaation WCtt Domestic/Private I Gravel Pack r v —�2 Dia. of Well Casing M Public n Other IX �] Tracy Type of Casing Specifications Cl Delta Depth of Grout Seal 1.��_ Type of Grout—BeC1toa tle_ I i Irrigation 5Approx, Depth I i Eastern Surface Seal Installed b Repair Work Done ❑ Type of PumpY H.P. State Work Done Well Destruction ❑ Well Diameter? Sealing Material (top 50') �l {;„ArDepth r' Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is „ available within 200 feet.) „ Installation will serve! R11 esidence 'Commercial -- — Other r- y . 3� ` ��t�' Number of living units: INumher of bedrooms Character of soil to}a depth bf'3'feet: I' ., z, •y SEPTIC TANK { Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 52, Distance to nearest: Well Foundation Property Line z LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation j �, � Property Line SEEPAGE PITS 11 Depth i Size Number SUMPS ❑ Distance to nearest: 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 r e e sip. Signed X Hennings Bros. ' Title: 'lJ 4-19-91 Date: OR DEPARTM USE ONLY II Application Accepted by Date r Area Pit or Grout Inspection by f pate Final Inspection by r ',,• Date Additional Comments: _0* 0(` ❑ Silk 466-6781 ❑ Lodi 369-3621p ❑ Manteca -7104 ❑ Tracy 835-63$5 c, � Applicant - Return all copies to: Environmental Health Patmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S CA 952 a�a ': eu�y ✓rte.- ��, I FEE AMOUNT DUE AMOUNT REMITTED INFO CK RECEIVED BY //�� CASH DATE PERMIT'NO. t i EH 14-281FEV.iiH 5f "vK `� �t ,�