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d 't �t2 APPLICATION FOR PERMIT SAN JOAOUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTCN, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR—FROM DATE ISSUED (Complete in Tr.plic3te) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereh'.described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or Nu. 1862 for well/pump and the Ruins acrd RegulMions of the San Joaquin Local Health Ebttrict. Job Address 27539 S. LAMMERS RD. Cty TRACY __ Lot sae PM q; Owner's Name SAW—P1S_H 0 S Address -3 1 FAST 6TH $1.__T-,QACC Phone ; Contractor HEMNGS_HBOS_ DR 1 I I _Address—3-5 2 5 P F I A N I)AIF A V E _License No._19_OZ 7_I—Phone S TYPE OF WELL/PUMF: NEW WELL (7 WELL REPLACEMENT Cl DESTRUCTION aQ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FI.D.__ PROP. LINE FOUNDATION _ AGRICULTURE WELL. OTHER WEI L__ PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indt'strial O Open Bonom O Manteca Dia. of Well Excavation Dia.of Well Casing I i ❑ Domestic/Private ❑ GravPI Pack ❑Tracy Type of Casing --_ Specifications 1.1 Public 11 Other r Delta Depth of Grout Seal Type of Grout—. t I I Irriflation __Approx. Depth I I Eastern Surface Seal Installed by— Repair Work Done L) Type of Pump H.P. Stace Work Done_ tt 1 Welt Destruction )VX Well Diameter 611 Sealing Material(top 501 —1.-0.0 REN�. TI-N I TE - ? Depth 210, Fillar Material(Below 501 — j TYPE OF SEPTIC WORK: NEW INSTALL i iGN ; I REPAIWADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living nnas:__ Number of bedrooms Character of soi!to a depth of 3 fast: Water table depth { SEPTIC TANK 0 Type/Mfg __ Capacity No. Compartments ( PKG.TREATMENT PLT.n Method of Disposal /A Distance to nearest: Well Foundation__ Property Line V LEACHING LINE ❑ No.&Length or lines Total length/site FIL-EER BED O Dista-,Le to nearest: We!!_- Foundation — Property Line ' SEEPAGE PITS l I Depth _—Size Number i SUMPS (1 G,stance to neArest: Well _ Foundaticn Property Line DISPOSAL PONDS L? I I hereby certify that I have prepared this application and that the work wil!be done in accordance with San Joaquin county ordinances,state laws,and a rules and regt:latiuns of the San Joaquin Local Health District. S 1 ify that in the performance of the work for which this permit is iastwd,I shah not Home ownar or licensed agent's signatula certifies the fnllowing:"I certf { employ any person in such manner as to become subject to workmar.'s compensation laws of California."Contractor s hiring or sub contracting signature i j certifies the following:"1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- { tan laws of California." The applicant must call for all required inspections.Complete drawing n reverse side. i Signed X H r N N I N G S R RyS. '1 R I L L I N G C 0.Tido: Date: 12-6-89 R 1 R DEPART" NT USE ONLY Application Accepted by _ �_. Dat,4_�Z Area 276' Pit or Grout Inspection by _ Date Final Inspection by Date r Additional Comments 0 Stk 466-6181 0 Lodi 369-3621 ❑Manteca 823.7104 0 Tracy 835 6385 lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 Applicant-Return all copies to: Environmental Hea CK 8G FETE AMOUNT DILE AMOUNT RtMITiED t AS,i RECEt'JED BY DATE PERMf-�NO. INFO — a EH 1124IREV.riNSt ..i_Q y 'J EH 14-2e — t t ` �' I