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lbkw' APPLICATION FOR PERMIT %%wW SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 4491 WEST DURHAM FERRY ROAD TRACY Job Address City Lot Size PM Owner's Name STELLA RUIZ SAME AS ABOVE {209 ) 835-7554 Address _ Phone Contractor SIERRA X DRILLING Address JEANINE DR. MODESTO 521617 578-9900 ddress License No. Phone TYPE OF WELL/PUMP: NEW WELL Xl WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 00 FT SEWER LINES X DISPOSAL FLD.100 FTPROP. LINE 15 FT FOUNDATION 25 FT AGRICULTURE WELL X OTHER WELL 35 FT PITS/SUMPS X INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 5 IN Dia. of Well Casing ❑ Domestic/Private Gravel Pack 1 Tracy Type of Casing Specifications ?CI cJTORING 171 Other fl Delta Depth of Grout Seat a Er Type of Grout CEMEpa _ I Irrigation Approx, Depth I I Eastern Surface Seal Installed by SIERRA DRII I ING Repair Work Done Ll Type of Pump H.P. State Work Done_ Well Destruction f7 Well Diameter Sealing Material Itop 501 Depth Fitler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f i DESTRUCTION I I iNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence — Commercial_ Other Number of living units: Number of bedrooms PA Character of soil to a depth of 3 feet: Water table depth R�!FRO YT SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Zi PKG. TREATMENT PLT. Cl Method of Disposal Distan•:e to nearest; Weil Foundation Property Line 7 IRAN LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well FoundationProperty Line /CE ( H i 5 SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS [] 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicst cal o equired inspections. Complete drawing on reverse side. Signed X Title: RILL ING pate: MAY 6, 1988 A2Z,�DEPARTMENT USE ONLY Application Accepted by Date J 2x"l'-k Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 AMOUNT REMITTED INFO CA H RECEIVED BY DATE PERMIVNO. . EH 13 24(REV.i/m 51 EH,..2e � S oto c»... ;!� �h