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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED I k 1601 E. HAZE T ON AVE., STOCKTON, CA d Telephone {209} 466-6781 APR 17 1989 PERMIT EXPIRES TYEAR FROM DATE ISSUED ` .ENVIRONMENTAL HEALTH {Complete in Triplicate} PERMIT/SERVICES 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. 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 S T.` - LOT #2 0City TRACY Lot Size PM f. Owner's Name SAY_ IARGOWSKI CONST, Address 27743 S_ CORRAL HOLLOW Rn-tracyrPhone Contractor_HENNINGS BROSRII I Pddress License No._-2_]0_fj1 3 Phone TYPE OF WELL/PUMP: IN EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK + SEWER LINES �O.!_�_ 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 1 2" Dia. of Well Casi g kX Domestic/Private IM Gravel Ptack Tracy Type of Casing_ 2 V C 6 O 0 i Specifications M Public M Other t C1 Delta Depth of Grout Seal A0 0 ' Type of Grout B _ ' I I Irrigation , _--Approx. Depth { I Eastern Surface Seal Installed by. HENNINGS BROS Repair Work Done ❑ Type of Pum P H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ttop 50'l Depth i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR./ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence, Commercial_ Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: 0 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Len th of lines g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I 1 Depth Size Number ( SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 4 rules and regulations of the San Joaquin Local Health District. li 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 I 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,f shall employ persons subject to workman's compensa- tion laws of California." t The applicant must call for all required inspections. Complete drawing orlpreev`ers side. It y .b ( 9a�'�• 1c1J7� 1r Signed X Title: Date: OR EPARTMENT USE ONLY Application Accepted by Date 'w Area / Pit or Grout�lnspection by Date Final Inspection by ate /1 �� ,i ' Additional Comments: ❑ Stk 456-6781 ❑ 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, Silk., CA 95201 FEE AMOUNT DUE AMOUNTREMITTED INFO RECEIVED BY DATE PERMIT'NO. i.EH 13-24 IREV.r/H 57 EH 14-2e _ _ Q �.' ` R-w