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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 County Ordinance No. 549 for sewage or No. 1R62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ., I 1 Job Address 27070 W. H I L L V I E W ST. L O T #23 city TRACY Lot Size PM Owner's Name Address RAY TARGOWSKI LONST. 27743 S. CORRAL HOLLOW RD YPhone *#.4 Contractor H E N N I N G S B R O S`. Address 3525 License No.2-9R&13—Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT k DESTRUCTION XI PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK 1 00 t } SSEWER LINES s OO I f DISPOSAL'FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f 2 Dia. of Well Casing 611 DQ Domestic/Private )E-)(Grave) Pack I(7)(Tracy Type of Casing Pyr, Specifications Fl Public CI Other 11 Delta Depth of Grout Seal u10 0.1 Type,of GrouNEAT_.CEMENT _ I I Irrigation —..Approx. Depth I Eastern Surface Seal Installed by NN L� IN-65_ BROS._ ]IRT 1 I F N G CID- - i Repair Work Done 0 Type of Pump H.P. State Work Done j Well Destruction EX Well Diameter Fi 'r Sealing Material (tap 5m NEAT CEMENT . Depth 160 ' Filler Material (Below 501 NEAT CEMENT TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is f available within 200 feet.) 0 { 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 0 Type/Mfg Capacity No. Compartments PKG_ TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS t I Depth Size Number `- SUMPS L7 r C41ance to nearesi Well Foundation Property Line ,fy DISPOSAL PONDS 0 Sid. 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 Di§trict. 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 t employ any persdn in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I{ 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 pprequired inspections. Complete dr g on reverse side. ' i c� Signed X P I �C GSl eA7) " Date: 1 I0.-1 L`0 FOR DEPARTMENT USE ONLY Application Accepted by Date -7 Area Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: dl� IA�P�� pSp 1 ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Man ca 623-7104 0 Tracy 835-6385 _._... I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED) CASH CK RECEIVED BY DATE PERMIT NO. a.EH 13-24 IREV.i/K 5) EH 14-28 �►�p �.e�..-fit--f�`� f�ri-�c �5�'t —I e 3 1-E