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'APPLICATION FOR PERMIT pAYME:Nr !! �. SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVE© 4 1601 E. HAZEL T ON AVE., STOCKTON, CA , Telephone (209) 466-6781 APR17 Jsgg t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL (Complete in Triplicate) PERMIT�S H&Q—M Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.'TFI sRa4liestion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. .s�-7 Job Address H I L L V I E W ST. City TRACY - Lot Size PM Owner's Name RAY TARGOWSKI CONST. Address 27743 S. CORRAL HOLLOW RD/TRACY Phone 835-2786 Contractor HENNINGS BROS. DRILLA,ddress 3525 PELANDALE AVE. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL (A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100'+ SEWER LINES 100'+ DISPOSAL FLD: PROP, LINE M FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 Dia. of Well Casing 611 (X Domestic/Private 00 Gravel Packs M Tracy Type of Casing : : 1600a PVC Specifications M Public 171Other j ❑ Delta Depth of Grout Seal 1001 Type of Grout46P _ I I Irrigation - ______Approx. Depth I I Eastern Surface Seal Installed by HENNTNGS RRDS f1RTI I TNG Repair Work Done ❑ Type of Pump; H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 �'. Depth I Filler Material (Below 501 TYPE OF SEPTIC.WORK: NEW INSTALLATION O REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is f ''1 available within 200 feet.) _J Installation will serve: Residence_I Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet-" ' Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line i 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 ❑ Distance tolnearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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: "1 certify that in the performance of the work for which this permit is issued, l 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." l The applicant must call for all required inspections. Complete drawing on reverse side. Signed XQWA M102�4 L �JLl -'1.1J1 x.-__-�_-.I,r-�F TitEe: 1Pr 5 S i'�. YYl Cr v Ela tares Date: 't`13 R D�RTMENTUSE ONLYApplication Accepted by FDate —IPA Area Pit or'Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M eco 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health wmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 14 I EEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. �+.EH1321 I REV. (o EH 11-28 o /! s