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APPLICATION FOR PERMIT y�--PAYMEN-r SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 MAY 2 5 1918 i i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NVIRONMENTAi HEALTH (Complete in Triplicate) 2-4&—,3 0—d 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 Local Health District. ` - Job Address Lot 9Ls��1 at,i•@ tR.f City. Tracy Lot Size PM Owner's Name arta_ D�.�� t f�_Qo - Address �?�;� )(_�4�1�� qtnr.! tan Phone 4799 ContractorHennings Oros_ Address 3525 pelartLle, MDd. License No, 290813 Phone 5451185 f TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT.E1 DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR"❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK 100 t SEWER LINES DISPOSAL FLD. 1001 PROP. LINE 1�t 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 1 tI Dia. of Well Casing 611 �X Domestic/Private 00 Gravel Pack Tracy Type of Casing Pte' Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout-3fflt0n l to I I Irrigation __ -Approxi Depth I i Eastern Surface Seal Installed by dri I I�r _ IV Repair Work Done ❑ Type of Pump H.P. State Work Done_ �1 s Well Destruction ❑ Well Diameter Sealing Material (top 501 c� Depth Filler Material (Below 501 1Wr TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 RE-PAIR/ADI]1TION 1-1 DESTRUCTION I 1 jNo septic system permitted if public sewer is available within 200 feet.) Installation will serve:,,Residences_L Commercial_ Other' Number of living units: Number of bedrooms Character of soil t,7a depth of 3 feet# Water table depth SEPTIC TANK ❑ .Type/Mfg -- Capacity^ N-o. Compartments. PKG. TREATMENT.PLT. ❑_. Method of;Disposal 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 r SEEPAGE PITS t I Depth Size Number SUMPS Ll Distance Ito nearest: Well Foundation Property Line DISPOSAL 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 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: "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." d The applicant must call for all required inspections. Comle- .drawing o averse side. Signed X Aitle: a ::.., Date.:'—.- 5-23-88 FOR DEPARTMENT USE ONLY Application Accepted by _ / 1 ' Date Area Area PitGro Inspection by _ Date ®Fina! Inspection by Date Additional Comments: /107 ❑ Stk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. +.EH 1324 IREV. /n 51 EH 14-26 11