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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVE,) 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 APR 7 1989 PERMIT EXPIRES VYEAR FROM DATE ISSUED (Complete in Triplicate) ENVIAONMENTAC FIEA4LT ER Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc�bed!'Ttfis4�4flon is made in compliance with Sari Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin f Local Health District., Job,Address H I L L V I E W ST. LOT#15 City -TRACY Lot Size PM ' 3 owner's Name RAY TARGOWSKICONST Address 27743_S CORRAI- HOLLOW OW RD/TRAACY Phone Contractor HENNINGS BROS. DRILLAddress 3525 PELANDALE AVE. License No.290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL 00 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK 1 OO l + SEWER LINES 100 t + DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of WVQJI Casing 6 r' ;1 Domestic/Private _ EX Gravel Pack UTracy Type of Casing 1_ 0 g a p V C Specitica I 00 r Type of Grout j l Public l Other ❑ Delta Depth of Grout Seal I Irrigation —._Approxi Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filter Material (Below 501 Q TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is r✓ available within 200 feet.) Installation will serve: ,Residence Commercial_ Other 0 Number of living units: Number of bedrooms +Jy Character of soil to a depth of 3.feet: + Water table depth v i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line l " l LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line I SEEPAGE PITS I I Depth I Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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." i The applicant must call for all required inspections. Complete ,drawing n,reverse side. Signed X 16M A-K_-r Title: .R-S.s h- fl( tN0. C r Date: r� 3 FOR ADEPRTAM4ENT USE ONLYApplication Accepted by Date Area Pit or Grout Inspection by - � /L!� Date JAr_ al Inspection by Date Additional Comments: l ❑ Stk 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. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED # INFO CASH RECEIVED BY DATE PERMIT�'NO. + EH 1 -24{REV. g —L t EH 144-29 ��s Q ��"