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APPLICATION FOR PERMIT ►. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 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. of Job Address South Corral Hollow Road citySouth SouthTracy Lot size P. 0. Bog 811 PM Owner's Name Co nol ly am , Tnc AddresTrAgy, CA PhA209 835-7915 1780 Vernon St. (916) Contractor P. C= FFP D a ion_AddressRoseville CA 9 678 License No.265556 TYPE OF WELL/PUMP: Phone783-9733 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 Monitor well DISTANCE TO NEAREST: SEPTIC TANK OTHER ? W 2 -. SEWER LINES DISPOSAL FLD. PROP. LINE/2 Z FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaI Dia. of Well Excavation Dia. of Well Casing �_- n ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T FI Public Depth of Casing p Cement— (1 Other ---'-YC Specifications fl Delta Depth of Grout Seal Tn l+n .1lnr I I Irrigation _.Approx. Depth I I Eastern "a—dote UineTdpe of GroutBentonite_— Repair Work Done ❑ Type of Pump H P Surface Seal Installed by Well Destruction El Well Diameter State..Work Done _ Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SWater table depth SEPTIC TANK � ❑ Type/Mfg Capacity PKG. TREATMENT PLT. ElNo. Compartments Distance to nearest: WellMethod of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ DiTotal length/size Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number DISPOSAL PONDS 11SUMPS L-I Distance to nearest: Well Foundation Property Line 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 DiMrict. 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 on reverse side. Signed X ;;?-1 Title: _ ?rem[ -P' Le Q n Date: 3—,P � F DV P MENT USE ONLY Application Accepted by r� Date Area Pit or Grout Inspection by �" Additional Comments: — ate Final Inspection by Date ❑ Stk 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 FEE AMOUNT DUE CK Ll AMOUNT REMITTED RECEIVED BY CASH DATE PERMIT-NO. EH 14-2,(REV.i i n s l �U ER.,,-2a 6 7yCC C