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• APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRIC0 RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 NOV 21 1999 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN CrjuI%!TY 1CMtPB r# rL+a rE�c'a�h h�+ra•,ri� (Complete in Triplicate) PUBLIC HEALTN'.fit"+ICES ENVIRONMENTAL HEALTH DIVISION Application is hereby made to the San Joaquin L cal Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Jdaq",county Ord ahce No. 549 for sewage or No:1862 for Well/pump and the Rules and Regulations of the San Joaquin Local Health District Job Address Defense be 'racy City Tracy . Lot Size " 448 acres pm _ Defense ' Logistics Agency,DDTC-WB Owner's Name Mr. Wesley Harris - Address 26500 Chrisman Rd. , Tracy phone (209 ) 832-9 36 ids - 7 49 Ajay Dr. ,Sun Valley Contractor AddressCh. 91 352 License No. 561265 Phone (811811767 222 TYPE OF WELL/PUMP: NEW WELL 63 WELL REPLACEMENT ❑ ! DESTRUCTION ❑1 )EXtractiOn PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ ` _ OTHER 632 )ZnJ ection DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 3_).Mon i tori g FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ! PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 17a v- pu cam_ Dia. of Well Casing VAyi n1l LI Domestic/Private Rl Gravel Pack IR Tracy Type of Casing PVC` Specifications n Public ❑.Other - ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation �_.Approx. Depth I I Eastern- Surface Seal Installed by Repair Work Done ❑ Type of Pump CentrifUgalj.lP.H.P. 1 1 .5 State Work Done Well Destruction ❑. Well Diameter Vart nn Sealing Material (top 501 Port-land ('empnt Depth "VariCius -- Filler Material lBelowsm Bent-nnitp S1t1 ry TYPE OF SEPTIC WORK: NEW INSTALLATION I I , REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is "- '- available Within 200 feet.) Installation will same:._Residence__ Commercial— Other . Number of living units: Number of bedrooms Character of toll to it 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. 6 Length�of lines : Total length/'size FILTER BED ❑ Distance to naarast: Wall Foundation Property Line SEEPAGE PITS I I ! Depth Size Number SUMPS Ll Distance to nearest• Well t 000dation 'Property Lina DISPOSAL PONDS ❑ i I hereby certify that I have prepared this applicdtlon and thst the work will!be done ih accordance with Sen Jgaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licansed agent's signature certified the following: "I certify that ih'the`performance of the work for which this permit is issued, I shall not employ any person in such manner as to becbme dubjeet to Workman'd compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the perforrhance of the wofk for which this permit is Issued, I shall employ persons subject to workman's compensa- tion laws of California." ,---� The applicant,mus all r II to i clions. Compl drawing on reverse side. Signed r tide:'President Date: _ 11 -6-89 -. I- . .. 0R bE ENf USE ONLY Application Accepted by , Data ` v Area Pit or Grout Inspection by I bate { Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 i O Manteca 823.7104 –❑ Tracy 835-8385 ; Applicant- Return all copies to: Environmental Health Permit/Servicet 1601 E. Hazelton Ave., P.O. Box 4009, Stk., CA 95201 t 'r INFO AMOUNT DUE AMOUNT BEMItTEO CASH RECEIVEp BY DATE. PERMIT'N0. 3. EHIJ211REV.i/x51 q EH 11-]a