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x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 J U L 1 5 1591 i PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SE"ViCES EtVIzOn t,ENTAL HEALTH 71Vial r,^a 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 Ordinarice No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. x Job Address 2440 MOCUSO .Rd. City Tracy _ Lot Size _40 $CrP- PM Owner's Name PombO Realty Address P.O. Box 805, Tracy Phone 835-4949 – Contractor Hennings Bros. Address 3525 Pelandale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL= WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100'+ SEWER LINES DISPOSAL FLD.--IO_Q L+PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 501 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 611 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing 1X Domestic/Private DQ Gravel Pack Tracy Type of Casing 4 PVO Specifications i fl Public Cl Other F Delta Depth of Grout Seal T pe of Grout Bentonite rifer � I I Irrigation —Approx. Depth l 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r Repth .2112. Filler Material (Below 50') TYPE OF SEPTIC WORK., NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I 1 (No septic system permitted if public sewer is 1 available within 200 feet.) O ji � . ,y. , ,,,� installation will serve:b Resi`dencel'-`� Commercial_ Other ' 49.19 Number of living units: Number of bedrooms ;••.,,; r:1kc, t 185 1;,•:r• , ' iT - t , • i.. Water table depth Character of soil to a depth'of 3 feet:' SEPTIC TANK ❑ Type/Mfg'l Capacity No. Compartments El PKG. TREATMENT PLT. Method of Disposal Distance to nearest:-0 r Well Foundation Property Line10 + I 60 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS l l Depth Size _ Number Cr'tsLJL4l f' SUMPS ❑ Distance to 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 t 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.'.' The applicant must call for all required inspections. Complete drawing on r se side. Signed x Hpnni ngg Rrng �B) Title: Date: 7-11-91 F DEPART NT USE ONLY cy Application Accepted by Date r If Area / Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 elD Tracy 835- 5 Applicant - Return all copies to: Environmental Hpialth Per /Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 X44_ !87 7 =- /Sp' FEE AMOUNT DUE 1 AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. INFO � +.EH 13-24 IREV.1/H51 o41I 0Z f� ` 'r' �'•! � ] '~ EH 14.26 WWW ` -