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APPLICATION FOR PERMIT SAN JOAQUIF. LOCAL HEALTH DISI RICT 1601 E HAZE'.TCN AVE STOCKTON CA „ rh1T Telephone (2091 466 6781 PERMIT EX_ PIKES 1 YEAR FROM DATE ISSUED t^ (Complete in Tnpht atel App'ica'lon is heiLby mode to the Sap Joaquin Local Health District for a permit to construct and,or irsiall the work herein described This apphCillsonr.1.�1r� made in comphancr with San Jadqu,n County Oid-nanro No 549 for sew age or No 802 for veil Dun p and the Rutesand Regulations at L'te5aIIIJC t in Local Health Drs rr_t E' I Imo, .) Job Address __ L8777 S. Tarr Pame Ave. _ C ty Tracy Lot Sipe PM Don Cose & ASSociatts A,dress P.D_.__4ox_326 L Tracy_ Phone _$3�-n422 Owner 5 Ndme — Co'ttractor HerinlnGS Brr7S. Add ess 3525 Pelandale Mod. License No 290aU_Phone 545-1189— TYPE 45 1TYPE 'JF WELLIPLIMP NEW WELL rA WELL REPLACEMENT G DESTPUCTICN ❑ Ir� r� PJM1 INSTALLA T ICN ,� SYSTEM REPAIR Li OTHER 0 101` 13 5 C a DISTANCE TO NEARcST SEPTIC TANK 100 t SEWER LINES DISPOSAL FLb �;t7� PROP LINE FOUNDATION AGRICULTURE WELL __ _ OTHE9 WELL PITS/SUMPS _ INTENDf0 USE TYPE OF WELL PROBLEM AREA COYSTRUCTION SPECIFICATIONS I IndustrialL, Open Bottom L Manteca Jia of Well Excavation " Dia of Well Casing rr XXDomesti, It rtvate XX Gravel Pack XX Tracy Tyre cf Cas nrj --P_VOt��Specfis cationn .,.,'+ 1 Public I I Other i Delta Depth of Groul Sedl I f LJ Type of GroutszaILtoni e__ Irrigatroi C�L Appiox Depth I r Edslern Su 1dLe Sadl Installed by, drt l lAr _ gepair Wcrk Done -1 Type of Pump HP _— Yate Work Done_ Well Oast ut,tion h Well Dra-neter Seaan1 Miierial trop 50 1 Depth_ Filler Malonal f9oio v 50' T YPE OF SEPTIC WORK NEIA INS1 At LATION i � Fit PAIR ADDITIOV I DES TNJCTION i (No sepric fv%tem permuted if puukc sewer is available within 200 feet I Instalr..+on will serve Residence_ Commercial Uther Numb-r of livir9 units Number of bed opms Chara:ter of soil to a depth of 3 feet Water table depth SEPTIC TANK I i Type/Mfq V _ Capacity _ _ No Compartments PKG TREATMENT PLT f 1 Method of D suosal Distance to nearest "lets W Fouriaiion Property Line i LEACHING UNE I No R Lengih of lines _ _. _ Total length'size_ FILTER BED E I Distan a to nearest Wt II _ _ _ Foundation _ Prope-ty Line EEGFAGE PITS Depth _ 5un _ __ Number I SU? PS i Distance 1n nearest WrFI _ F�.,nAau n _ _ Property Lins i DIS'oSAL PONDS SI hFreby certify that I have prepafec this appfical�on anj the the work will hi Joni in accordance with San J,mqum comty ordinances state taws and ruks and regulations of the San Joaquin Local Health D'stnrl Ho no owner or licensed agent s signature certifies the following 1 certily th„1 m the performance of the work for which this pernut is issued I shall not employ any person in such manner as to become sublrtcr to we Lmau s compensation Laws of California Contractor s hiring or sub-contracting signature ca hfies the following I certify that in the performance of the wurk for which this porm,r is issued I shall employ persons subject to workman s compensa tion Laws r.f California Tile applicant roust call for all required inspections Complus drdw-ng on re kiss ,ado/ r — Sgr,d X Hen i -�_Br-QS- Bx _ Tit 1 1 --- 1 Date 4-28-88 i FOR DEPARTMENT USE ONLY 1 /` i i t. itppjicatrnn Accepts t by ___6. Date ! _ Area a Ir ��r� L L' Ua a�✓ Final Inspection by y` ,' `� Date r T I a li t or Grout inspect on by _ Addaioral Comments —_— _ Stk 466 67,81 Lodi 369 X21 "Manteca B23 7104 -, Tracy 8.35 6385 Applicant Return all copies to Environmental Health Parmrti Services 16C' E Hazelton Ave P 0 Box 2009 Stk CA 95201 FEE AMOUNT OUr AMOUN- RE41T'TFD ��K RECEIVED ay DATE EPFFIMIT -40INFO /�3