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,r APPLICATION-FOR PERMIT r 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Rd. , west side Jab Address 29879 Chrisman Rd.-3/4mi. south of LinneCity Tracy Lot sire 164'x275' PM _ Owner's Name Wm. Edwards & Son Address 6352 W. Canal Blvd. , Tracy Phone 835-4651 Contractor Hennings Bros. Address 3525 Pelandale, Mod.. . License No. 290813 Phone 545--1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 111 t SEWER LINES DISPOSAL FLD. �!- PROP. LINE FOUNDATION T AGRICULTURE WELL OTHER WELL -PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'r XXDomestic/Private XXGravel Pack XX Tracy Type of Casing PUO Specifications f 1 Public D Other ❑ Delta Depth of Grout Seal 100' Type of Grout Bentonite_ { I Irrigation _ .-Approx. Depth I I Eastern Surface Seal Installed by driller Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) Installation wiOserve: Residence r' Commercial_--_ Other Number of living units: Number of bedrooms Character 048wio a'depthrof 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments F 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 �I }` SEEPAGE PITS i'I Depth Size Number , it i.f•r,., 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 Di3trict. 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, 1 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 certifies the following: "1 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 inspections. Complete drawing o erre side Signed X Hennings Bros- Title: Date: OR REPAR ENT USE ONLY Application Accepted by 4Date Area Pit or Grout Inspection by Date Final Inspection by d�.s Date �T $rrt5 r Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Mentece 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. ..EH1144-28-24(Rl-V.t i H 51 EH g r 027 r C7 1"J t.7 It- 00