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APPLICATION FOR PERMIT PAYMENT t ,O SAN JOAQUIN LOCAL HEALTH DISTRICT y"?;��'REGE�VED ii 1601 E. HAZELTON AVE., STOCKTON, CA rJIAY 2 Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMITISERVICES ibe n descr d. This madle n i ompliance writhade Satn Joaquio the n Counqty Ordinance Nto.549 for sewage o n Joauin Local Healh District for a permit to 1862 for construct and/or and the Rules and IR Regulations of the Sancationis Joaquin Local Health District,. gY� c_vi for=nascero Estates p, 1-17fCity, TracyLot Size PM 1' Job Address Lo Owner's Name Delta Development Co,�. Address P. BOX 7414 Stockton Phone 474-9922 Contractor Address License No.240�1�—Phone ' TYPE OF WELL/PUMP: NEW WELL CX WELL REPLACEMENT -❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK _- `t— SEWER LINES DISPOSAL FLD. 100 PROP. LINE _10-1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing II ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications 2 IX Domestic/Private Gravel Pack Tracy g 1 Type of Grout_-Benton it`—. L1 Other D Delta Depth of Grout Seal 1-1 Public i Surface Seal Installed by driller _ I 1 Irrigation �..-Approx, Depth I ! Eastern Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') I; TYPE OF SEPTIC WORK: NEW INSTALLATION 11 RFPAIRIADDITION i I DESTRUCTION l I (No septic system permitted it 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:, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT.,D Method ofrDisposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I i Depth Size Number SUMPS LI Distance to neatest: Wel! Foundation Property Line I , DISPOSAL PONDS ❑ i I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 'C 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, 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 1 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 + II The applicant must call for all required inspections. Complete drawing on r verse i e. Si ned x .4ennings Bros_ y Title: Date: g FOR DEPARTMENT USE ONLY j� Application Accepted by -- Date 5t Area v Pi �inspection by Date Final Inspection by Date Additional Comments: D Stk 466-6781 ❑ 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. INFO f'] v�f ^� +.EH 13-24(REV.i i x s 1 !Q 1 0 ' EH 14-2e ! r i