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APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE--1 ON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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 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' " " Job7ded,ss VALPIC0'RD: -.(.tideSt Of well. #1 ) City TRACY Lot Size PM j Owner's Name DELTA DEV . -C0. Address R.-O. B 0 X 7 414 S T 0 C K T O N Phone 3 4`3 contractor KENNINGS BROS. -DKILL,address 3525 PELANDALB AVE, License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL CX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -DISTANCE TO NEAREST:.SEPTIC TANK 1-0 0 SEWER LINES 10 0 DISPOSAL FLD. •PROP.-LINK - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS z ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5 1 1 IX Domestic/Private X7 Gravel Pack IX Tracy Type of Casing PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1,o o Type of Grout BENTONITE EJ Irrigation ---Approx., Depth ❑ EasternSurface Seal Installed by H E N N Gs BROS. DRILLING CO. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material )Below 501 C TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ' Residence}_, Commercial— Other i+ ; Number of living units: Number of bedrooms , Character of soil to a depthof3 feet: Water table depth f. ; G SEPTIC TANK ❑ Type/Mfg Capacity Na. Compartments PKG. TREATMENT PLT. EJ, < ti Method of•Disposal �f5 Distance to nearest: Well Foundation Property Line 1, a LEACHING LINE ❑ No. & Length of lines Total length/size . FILTER BED Ll Distance'to nearest: Well Foundation Property Line , i SEEPAGE-.PITS ❑ Depth Size Number ---z: ;i ; SUMPS - = ID. Distance to-nearest: – _ 6 Well Foundation .,Property-Line [1-1z -4 _ —.– DISPOSAL PONDS -.- i' 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." I The applicant must call for all required inspections. Complete d�ral"ung on reverse side. Signed V��c1�]�ptj" ASSIT. MANAGER Date: 12-29-86'' ' 1< �— _ FOR DEPARTMENT USE ONLY r M { Application Accepted by a.— Date >� 4 Area 3 � Pit or Grout Inspection by E Date Final Inspection by ,. Date t Additional Comments: ! i' ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca SM-7104 . '0 Tracy 835-6385 Applicant- Return all copies to: Environmental HealtK Permit/Se'rv'ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -- FEE AMOUNT DUE CAZAAMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO +EH M24IREV.1/a 5) —7 'EH W28 / ,c'�. 1-7 A3 C�C'r 1 i/ S'tQ 4