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APPLICATION FOR PERMIT VE E rLD SAN JOAQUIN LOCAL HEALTH DISTRII•CT EmE I 1601 E. HAZEL T ON AVE., STOCKTON, CA 3 1991 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Ip Triplicate) FERNIIT/SERVICES Application is heieby made to the San Joaquin Local Her�� it to construct and/or install the work herein described. This application is ��1�d made in compliance with San Joaquin County Ordinance �ABd�1ultgryNo. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �) 13 1 1991 Job Address ---COrral.__RQUow-_Road SAN JOA UIN COUNTY City S. of Tracy Lot size PM PUBLIC HEAL I � St. Ph sics InternatioWJ\J1R0N, %d%AL 4WC 4 Owner's Name _ Y _ __ g-- dress s&a$_Leand -off GA-94 Phone 415) 357-4610 (916) 1780 Vernon St. Contractor P.C: E�loration Address--ft License No. 965556 Phone 782-9733 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N 3 monitor wells i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE corner of ec on 24 FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industrial El Open Bottom El Manteca Dia. of Well Excavation 10�-- Dia. of Well Casing 4n Cl Domestic/Private ❑ Gravel Pack 17 Tracy Type of Casing PVC Specifications cement— F) Public (1 Other [1 Delta Depth of Grout Seafro be de �IIedype of Grout�EE11tO Ate__ I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by P C. F.Mnloration Repair Work Done 13 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 501 v Depth . Filler Material (Below 50'1 ----- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: __ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L.1 Method of Disposal Distance to nearest: Well _ Foundation. Property Line LEACHING LINE Ll No. & Length of lines Total length/size _ FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size __ Number SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS LI I hereby certify that 1 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 Dil;trict. 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 f r all required inspections. Complete drawing on reverse side. ,/ Signed X_._-_56� t� �'-�"^�- Title: i`rte 4� Le��'µ• Date: FOR RTMENT USE ONLY 1-f 12S Application Accepted by Date fa—__ Area 7 Pit or Grout Inspectio y Date Final Inspection � by .67 f Date Additional te Additional Comme : �h S 7� VCCy // I-) Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82 -7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 o?el,S `2' S FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEE' PERMIT'NO. EH 13 24 IREV,i i H ) a2 EH 14-28 V ' V