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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZEL TON 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. Job Address 5690 W. California Ave. Lot C city Tracy Lot Size PM i Owner's Name J.D. Most Const. Co Address 3941 A Holly Dr. Tracy Phone 835-6921 Contractor Nnin s Bros. Address 3525 Pelandale Mod. License No.290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL IFF WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 t SEWER LINES DISPOSAL FLD. 100' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + ❑ Industrial 9 0.Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of Well Casing 611 Domestic/Private U Gravel Pack Tracy Type of Casing Specifications _ f I Publicf 1 Other 17 Delta ° Depth of Grout Seal Type of Grout entoaUp I i Irrigation --Approx. Depth I I Eastern Surface Seal Installed by_ dri-l-ler Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 V! TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is s 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: - Water table depth E SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ 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 i 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 ins p g q inspections. Complete drawing o revers side. Signed X Hennings Bros. B Title: DDate: 11-1-89 FOR DEP TMENT USE ONLY Application Accepted by Date C Area_ Pit or Grout Inspection by ` Date Final Inspection by Date 1116 14�� Additional Comments: o'er / d ial © Stk 466-6781 ❑ Lodi 369-3621 ❑WAanteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY CASH if GATE PERMtTNO. , i•EH 1126fREV.tin51 0 �M� - �--�~ ��l� T9