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ITr—_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ppYME�- 1601 E. HAZEL ION AVE., STOCKTON, CA RECEIVER ! Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED APR 19J9 .�. (Complete in Triplicate) ��', �TfAlhis'�E�iCat ion is Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the w� E��I an Joaquin made in compliance with San Joaquin Coin Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules ant Local Health District. -T 02 ", TRACY Lot Size PM Job Address HILLVIEW ST. LOT #23 city Owner's Name RAY -TARGOWSKI CONST. Address 27743 S. CORRAL HOLLOW RQ TRA"one 835-2786 185 Contractor hIENNINGS BROS. DR L Address License No. UCTiO3 Phone – TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUGTION ❑ PUMP INSTALLATION ❑ ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _tD_Q2_+– SEWER LINES 1 D r -i- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n LlIndustrial fl Open Bottom ❑ Manteca Dia. of Well Excavation 1 11 Dia". of Well assn Type of Casing�gg.-s– C — Specificatia I]0 Domestic/Private }()(Gravel Pack racy Type of Grout ["1 Public Cl Other F] Delta "Depth of Grout Seal 100 I I Irrigation _____Approx�Depth l 1 Eastern Surface Seal Installed by ENNINGS EROS. DRILLING + H P State Work Done Repair Work Done ❑ Type of Pump t 1 Well Destruction ❑ Well Diameter Seating Material ltop 50'1 4 -Depth Filler Material lSelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLDESTRUCTION I I (No septic systhin m feet.' if public sewer is INSTALLATION 1 l REPAIR/ADDITION I-1 Installation will serve: Residence_I Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet:' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ ✓ Distance to nearest: Well Foundation Property.Line 1 / LEACHING LINE ❑ No. & Length of lines Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line h (� ,. SEEPAGE PITS L 1 Depth I Size Number l4}. SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 l rules and regulations of the San Joaquin Local Health Dihtrict. e following: "I certify that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signature certifies th 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 n reverse side, pct ' d X itle: 4 10 S: Q C k — Date: Signe OR EPARTMENT USE ONLY ,Date Date�Q` Area r Application Accepted by Date Fina! Inspection z ^ � Pit or Grout Inspection by by i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca H23-7104 ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 0 xA2009, Stk., CA 95201 1 r�r 8"1 ,. IDu-.,,.fie r,. �F'..�r1"u-s) `-O•C- FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH 7 ♦ EH 13-24 WEV.I/n sl G� L.aj EH 14-26 i