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I _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t {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., PARCEL 214-180-22/ Job Address TRACY BL -3 City Lot Size 214-184-23 pM Buil . I Owner's Name APPIAN ENGINEERING, INC.Address 760 EAST CAPIT L AVE, Phone 408-946-2677 fail�,E ya S 2a�_c�9s 2 Contractor GLENN MARTELL Address 1818 LOVERIDGE RD. License No. 510952 Phone 415-432-428 TYPE OF WELL/PUMP,: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Gt?E�S DISTANCE TO NEAREST:,SEPTIC,TANK., UNK_ SEWER LINES UNK �-• _ DISPOSAL FLO. T7_NK_ PROP. LINE IMK FOUNDATION UNK AGRICULTUR"ELL rC7NKOFHER LNE!L UNK ' PITS/SUMP5UXIj{ m INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack X Tracy Type of Casing Specifications I'I Public Cl Other FI Delta Depth of Grout Seal Type of Grout _ ! I Irrigation --Approxi Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well structioy ❑ Well Diameter $" .-_ Sealing Material (to 50'i CEMENT GROUT t�c.c.. /-15 Y 1-, 9 P - r} z Depth Filler Material {Below 50') CEMENT GROUT 141 LS" 0 TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION l IDESTRUCTION I (No septic system permitted if public sewer is 1 available%viihin 200 feet.)" i Installation will serve: Residence Commercial— Other c a Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: SEPTIC TANK # Water fable depth I ° ❑ Type/Mfg: Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal ,<t. Distance to nearest: Well Foundation Property Line W LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation i t Property Line r I SEEPAGE PITS I I Depth Size Number k SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C! J 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 DI - A 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 subjaci to workman's compensa- tion laws of California." The applican ust call fo at)required i spections. Com I Ing on reverse side. µ Signed X \ { ! Title: PRESIDENT s= > .� . � Date: 4/22/91 QR DEPARTMENT USE ONLY .' Application 46i opted by t Date 5.4 Area -.2 (C Pit or Grout Inspection h, Date final Inspection by `C��o`^�: i Date rvu! t �In cS �T � �. ct`fi/e a6Additional Comments: ' r❑ Stk 466-6781 ❑ Lodi 362Manteca 823 711)4 III, I ❑ Tracy 835 6385 S.ice . d 7 s952"�F/r Applicant- Return 811 copies to: Environmental'Health Permit/Services 1601 E. Hazelton .Ave„.P.0. Box 2W9, Stsk.,w CA 01 FEE CK rrS a1 d INFO AMOUNT DUE AMOUNT REMITTED' _ `a RECE]YED 6Y DATE VERMIT'NO. +.EH 1324 I REV,I/ a �` 4� err EH 14-26 iC�0• v v •t/ [/ /�/+l ,� S' / W �/� � ca a�„ �” :