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1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applica/�ni:"heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ,;; made tin 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. CORRAL HOLLOW & BYRON ROADS City TRACY Lot Size PM Job Address _ CITY OF TRACY Address 520 TRACY BLVD.—TRACY, CA Phone 209-836-9193 Owner's Name 2G 527-4940 QUALITY CONTROL INSPECTION 1295 N. Emerald Sierra DrillAo@&ss 611 S. 9th St. H License N7,575_ 21617 Phone 578-9900 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Z PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)( SDIL &KIA16S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing k ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ - - qtr • I 0-9 l Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing F1 Public L] Other F-] Delta Depth of Grout Seal f o 4^ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by H P State WFDone Repair Work Done L1 t Type of Pump I II IJUJ Well Destruction ( ] Well Diamet�r ' Sealing Material (top 50'1 Depth 1sZ/_I S Filler Material (Below 501 s `�, ��od iublrc sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I availa h l�C Installation will serve: Residence _— Commercial _ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: _ --- - SEPTIC TANK ❑ Type/Mfg _ Capacity_—__.-- No. Compartments Method of Disposal PKG. TREATMENT PLT. C] Distance to nearest: Well ___-- Foundation _-_—_ Property Line ._ Total length/size__-_--- LEACHING LINE C] No. & Length of lines FILTER BED ❑ 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 I ] 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 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 California.' The a lica t ust call for It egyired inspections. Complete drawing on reverse side. 4-7-88 Sig d X1 _ Title: --]^—� (1-^�_- - Date: -- `��. OR EP Date Area Application Accepted by Pit or Grout Inspect' y Date__ Final Inspection by -_-___ Date Additional Comments: L] 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 CK R FEE ECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH � ' . EH 13-24(REV.i i r+5) INFO EH 14-26