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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED d (Complete in Triplicate) r 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 wall/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job 1785 N. Corral hollow Road city Tracy Lot Size PM PM Robert Barenchi 1785 N. Corral Hollow Road (209) 478-6327 Owners Name Address Phone iesn-ss� r�wwrart rte s•+e. (209) 537-5767 Contractor(b,. �,.,.�,.®,�,Le ess 2523 River Road Modealg40lense wo.446670 �Itone TYPE OF WELL/PUMP: NEW WELL b WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ([tlOnit� ng) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 2.0" ❑ Domestic/Private ❑ Gravel Pack Wracy Type of Casing PVC Specifications SCh 40 I1 Public mpther n Delta Depth of Grout Seal –10 Type of Grout Beoni to I I Irrigation 2!Approx. Depth I I Eastern Surface Seal Installed by0ste— r e� i:g—M nt ewart Inc. Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material (top 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION i I DESTRUCTION I I (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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. m Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS O 1 hereby csrdly that I have prepared"application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and rules and(apuleions of the San Joaquin Local Health O trict. Home owner or licensed agoWs signature carWiss the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such martmer as to become subject to workman's compensation laws of California."Contractors 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 Califomia." The applicant must or allr twitc�s.,�C,,omplete drawing on reverse side. Signed Xeja iV1Pc Title: Date: ,f FOR DEPARTMENT USE ONLY 9 J Application Accepted by Date_H r �' ' Area S c 7 Pit or Grout Inspection by Date Final Inspection by Date Ad&dor. l Comments: O Stir 4064781 O Lodi 3694MI O Mantsea 823-7104 O Tracy 835-6385 Applicant-Retort all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO i . of 13-24 WAV.r, I C) s