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F � x E APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 II 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. 1: Job Address 20669 Naglee Rd. City Tracy Lot Size PM " Phone 836-2716 Address 225: p'rtf,-, rnri �f nr+. S�L (cense No. :-�U Phone 7k� ,COnfraCl6r" h ArtI—Address TYPE OF WELL/PUMP: a' DISTANCE TO NEAREST INTENDED USE ❑ industrial X1 Domestic/ Private F] Public I 1 Irrigation Repair Work Done ❑ Well Destruction ❑ NEW WELL WELL REPLACEMENT ❑ DESTRUCTlON'� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEPTIC TANK 200'+ SEWER LINES DISPOSAL FLD. 2001+ PROP. LINE'S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom Gravel Pack Cl Other '-Approx. Depth Type of Pump Well', Diameter Depth TYPE' OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION Installation will serve: 'Resid'ence — Commercial = Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG.,TREATMENT PLT. ❑ 14 Distance to nearest: - Well i." ❑ Manteca Dia. of Well Excavation fX Tracy Type of Casing PVC Cl Delta Depth of Grout Seal 100, I Eastern Surface Seal Installed by H. P. State Work Done Sealing Material (top 501 Filler Material (Below 501 LEACHING LINE FILTER BED SEEPAGE PITS ❑ No. & Length of lines ❑ Distance to nearest: Dia. of Well Casing 8° Specifications Type of Grout Bentonite driller (No septic system permitted if public sewer is available within 200 feet.) Water table depth _ Capacity No. Compartments Method of Disposal Foundation Property Line Total Well - Foundation Property Line l I Depth Size Cl Distance to nearest: Well Foundation Number Property Line DISPOSAL PONDS ❑ :! I Alk r. 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, a, ' ni ruleSLand 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: "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 n%ravMILL" / Date: 11-16-88sign+�d x a"�1?nnin s Bros. B Title: OR DE ARTMENT USE ONLY Application Accepted by Date �>ry Area 1�; Pit or Grout Inspection by Data ") Final Inspection by Date w. Additional Comments: ❑ Sfk 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 .,f 1 w i ♦-EH 13.24IREV.1/95 EH 14-28 FEE INFOAq AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT' No. 70 j �t / �,l/ �� 7,,� 61` 1 i:� �r a 4Z. 'JUS