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. .; APPLICATION FOR PERMIT V SAN JOAQUIN LOCAL:HEALTH DISTRICT RECEIVED 1601 E. HAZEL i ON AVE., STOCKTON, YMENT CA Telephone (209) 466-6781 APR 17 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH � j� licauon is lw'=n Joaquin Application is he+eby made to the San Joaquin Locale Health District for a permit t. construct and/or install the work here' made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and egu t Local Health District. �? �V Job Address H I L L V I E W S T LOT #2 1 City R Lot Size PM RAY - T A R G O W S K I C O N S T . �lPhone Owner's Name Address 27743 Contractor HENNTNG RROS DR Address _ r525 DCI AAkr1Al F AIIF_ License IVIS. 2TION�� -Phone - TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ 0- DISPOSAL . _t OSAL FLDPROP. LINE t SEWER LINES - i DISTANCE TO NEAREST: SEPTIC TANK _1QQ- - AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION _�— _ --� IL- "'" "�"'` INTENDED USE TYPE OF WELL PflOBLEM AREA n CONSTRUCTION SPECIFICATIONS u ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1_�� Dia. of Well Casing d Industrial Specifications Type of Casing E)(Domestic/Private Gravel Pack [ Tracy t Type of Grout - C1 Other 1-1 Delta Depth of Grout Seal NQS ROS ('1 Public 4 I NNI.. 'r_RR— I I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by i - H P State Work Done k Repair Work Done ❑ Type of Pump "4 Sealing Material Stop 50`1 te Well Destruction ❑ Well Diamer ( Filler Material IBelow 50'1 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAlRlADDITION l 1 DESTRUCTION l i anvailableseptic wthin 200 feet.) if Public sewer is Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments ClType/Mfg Capacity SEPTIC TANK+ � Method of Disposal PKG. TREATMENT PLT. ❑ Property_Line C Distance to nearest: Well Foundation 4� 1 t 1 Total lengthlsize LEACHING LINE ❑ Na. & Length of lines FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line I I Depth I Size Number SEEPAGE PITS Property Line SUMPS Ll Distance to nearest: Well Foundation r = DISPOSAL PONDS. ❑ µ I hereby certify that l 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, 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: u 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. Comp al e n reverse side. ! v��'" S\ r Date: . Signed FO DEPARTMENT USE ONLY Date Area ` Application Accepted by Pit or Grout Inspection by Date Final Inspection by ate C( :'Id Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 CO3nteca 823-7104 ❑ Tracy 835-5385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 1'. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 fid. I K—7' 7�- r FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO rEH 13-24 iREV. k -70 EH 14-26