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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District: Job Address 19224 S. Carrolton Ave. City Lot Size235vdsx425yds PM i - Owner's Name Wes MC Cann Address 1127 Chapel ,Dr. , Santa Clara Phone 408-241-6491 Contractor Hennings Bros. Address 3525 Pelandal License No. 0813 Phone . 545-118S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT . DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER_ M DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 451 OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom I� Manteca Dia. of Well Excavation �atr Dia. of Well Casing u ❑ Domestic/Private IN Gravel Pack ❑ Tracy Type of C PVC Specifications I") Public n Other F1 Delta Depth of Grout eal O E `er Type of Grout BentaLl i1e__- IXIrtigation r�/�„Approx, Depth l 1 Eastern Surface eal Ins tilled by driller Repair Work Done ❑ Type of Pump H.P. A State Work Done Well Destruction ❑ Well Diameter S alis gM� (top 50'00 Depth elow ) TYPE OF SEPTIC WORK; NE LLATION 1.1 RI ITIO I I ES CTION l I INo septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Resid nce_ mmercial_ Number of living units: Number of drooms ! Character of soil to a depth o 3 feet: Water table depth SEPTIC TANK ❑ T e/MfgCap rty No. Compartments PKG, TREATMENT PLT. UMethod of Disposal Dist nce to nearest: Fo dation Property Line r LEACHING LINE ❑ No. & ength of lines Total length/size ll FILTER BED C1 Distance nearest: Well Foundation Property Line SEEPAGE PITS l 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 Oiltrict. 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." Contractors hiring or sub-contracting signature canifies the following:"I certify that in the performance of the work for which this permit is issued, employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete draw' g o ide. . Signed X Tit Date: R DEP TMENT USE ONL Application Accepted by Date �` L_` Area r Pito put spection by ate Final Inspectio by Date Additions! Comments: - ❑ Stk 466-67131 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-63$5 Applicant- Return all copies to: Env'r nmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 fl�rw/ilm�ir�fr.ye• FEE AMOUNT DUE AMOUNT REMITTED INFO ...rrrJJJ GASH REC D BY DATE PERMIT'NO. + EH 13.2 lflEv.11 N 51 �S 460 r' EH 11.28 O -CJ.n X5__ D `I �