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APPLICATION FOR PERMIT *k. PAYMENT J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) . PEPIMITJSER,\/ICES Application is heqeby 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 vvew pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 27460 !Casson Rd.. City TraCy_ Lot Size PM Phone Owner's Name William Baker_ Address. 215 3 Corral lLd-a-lo. 35P,e . n e , MQdeStaense N29OS;1_3_Phone Contractor Hennings BroSa_Address 25 -a - TYPE F WELLIPUMP: a NEW WELL 1-Y, WELL REPLACEMENT E DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 DISTANCE TO NEAREST; SEPTIC TANK q. 100JI. SEWER LINES _ DISPOSAL FLO. 100' PROP. LINE FOONDATION,— AGRICULTURE WELL — OTHER WELL— PITS-/SUMPS INTENDED USE T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7 M Industrial Cl Open Bottom 0 Manteca ,. of Well Excavation—AIL— Dia. of Well Casing D XI Domestic/Private IX Gravel Pack Tracy Type of Casing— Specifications Depth of Grout Seal lj:10!� Type of Grout—Ren:t—r� 7 Public Cl Other F1 Delta I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by C> Repair Work Done El Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 sewer is OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (Nailablo septic system permitted if public s ave within 200 feet.) Installation will serve.: Residence Commercial Other Number of living units: Number of bedrooms Water table depth 0 Character of soil to a depth.of 3 feet: SEPTIC TANK El "Type/Mfg Capacity— No- Compartments PKG. TREATMENT PLT. 0 ;., . 1� , 1 Method of Disposal Distance to nearest: Well Foundation Property Line 4 T� LEACHING LINE 0 No. & Length of lines Total length/size- r Distance to nearest: Well Foundation Property Line FILTER BED LJ SEEPAGE PITS 1. 1 [�i' Depth Size Number SUMPS 0 1, Distance to nearest: Well Foundation Property Line --bISPQSAL:PONDS 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: "I certify that in the.performance of the work for which this permit is issued, I shalt 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 'do The applicant must call for all required inspecti V. Complete drawing on rave Signe I enningg pros. By Date: H------ , PARTMENT USE ONLY Date Area Application Accepted by Pit Inspection by Date�✓—�p Final Inspection by Date Additional Comments: 1-1 Sik 466-6781 El Lodi 369-3621 Dranteca 823-7104 FD1 Tracy 835-15385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NT DUE AMOUNT REMITTED =FIECEIVED BY DATE PERMIT NO. FEE AMOUNT D CK CASH INFO EH 13-24(REV._1 9 5 7f EM 14-28