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olq - APPLICATION FOR PERMIT ,h x SAN JOAQUIN LOCAL HEALTH DISTRICT x''AYivi h1� " 1601 E. HAZELTON AVE., STOCKTON, CA R>£CEIVE0 Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUL 1990 j (Complete in Triplicate) FNVIRONME`,T'd� iv a fft1dDation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hei`eiYng�y{j(F&c Joaquin made`ih compliance+niit_h`Sarfioattuin'�ourit�,Ordiiafice Nb 5�t9 for sewage or No. 1862 for well/pump and the Rules and Regulation 51— Local"He alth'Distnct. Job Address 21530 Na City Trac Lot Size 150'X349' PM Owner's Name 323 Evans St. , Tracy Phone 835-0586 Raul Mara Address Contractor Kennings Bros. Address 3525 Peiandale, Mad. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .. ...- -- DISTANCE TO NEAREST:_SEPTIC,TANK _ 100' SEWER LINES DISPOSAL FLD. 100 t+PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Err ❑ Industrial ❑ Open Bottom L] Manteca Dia. of Well Excavation Dia. of Well Casing PVC Specifications [X Domestic/Private X1 Gravel Pack )1 Tracy Type of Casing 1001 Type of Grout Be11tOn Ite t'1 Public ❑ Other F1 Delta Depth of Grout Seal I 1 Irrigation .Approx. Depth I 1 Eastern Surface Seal Installed by driller _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Seating Material (top 501 Depth Filler Material (Below 50') — I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is I available within 200 feet.) f Installation will serve: Residence, Commercial_ Other C 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. El 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 SEEPAGE PITS l 1 Depth Size Number SUMPS -Ll "Distance to nearest: Well `Foundation-- Property Line;- DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an� 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." The applicant must call for all required inspections. Complete drawing o verse sid Signed X 1-E)A pp i A R rn— ,..�_�l Title: Date: 7-25-90 FO DEPAR ENT USE ONLY Application Accepted by Date Area f Date 9/t3 �B F Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 me 823 ❑ Tracy -6365 Applicant Returrn�ll copies to: Environmental Health PPermit/Servic/es 1601 E. Hazelton Ave. O. Box 2009, Stk., CA 952001 C3 r 0 — 135 - �i'r � -- OU t�Gl C.LCS"�Y1�}(�! .`�• O Z e o-CQ FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATS PERMIT'NO. !! INFO r.EH 13-24(REV.,/H 51 EH 14-2a L4 ' a 3