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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMF_11T '� _ J — REGEIVED '� 1601 E. HAZE I ON AVE., STOCKTON, CA "Telephone (209) 466-6781APR lg$� Of f PERMIT EXPIRES 1'YEAR FROM DATE ISSUED s .(Complete in Triplicate) ENVIRONMENTALrr14�CCALTr ! Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work 1�t ��s �f.1`flti�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 i Local Health District. 2rj/2 Lo. Job Address HILLVIEW LOT #199 City TRACY Lot size PM S i " Owner's Name RAY TARGOWSKI .CONST Address Phone Contractor_HENNINGS BROS, DRIL1 Address License No. E�81�Q Phone 545-1185 -� TYPE OF WELL/PUMP: NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:,SEPTIC.TANK __1_0_0't_ SEWER LINES 100_!_x— DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation 12 rr . -_ Dia. of Well asi Ir Domestic/Private MGravel Pack JC Type of Casing_ 1 �d PV ' Specificatio M Public U1 Other Cl Delta Depth of Grout Seal J OO 1 Type of Grout _ I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by H E N N I N G S B R O S. DRILLING _ Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ! TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I'I" DESTRUCTJON I I Mo septic stem permitted if D Y p public sewer is available within 200 feet) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EIType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t t LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ! I Depth Size Number SUMPS - El 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 rules and regulations of the San Joaquin Local Health Diltrict. 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 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: "1 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 tali for all required inspections. Complete drawin reverse side. Signed X 1 ,r c� O Title: e r Date `f`! 3 ^8 f WR DEPARTMENT USE ONLY Application Accepted byL—ArDate S Area , r Pit or Grout Inspection by Date Final Inspection by Date 6LL1 7� Additional Comments: � leg g�" ❑ Stk 466-6781 ❑ Lodi 369-021 ❑ Manteca�S23-7104 ❑ racy 835-6385 Ap Ica t Return all copies to: Enviro I Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r7 6 IR r INFO AMOUNT 16 AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. +.EH 13-24 VIEV.I/H b7 EH 1428