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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 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. Linne Rd./, west side , , Job Address 29929 Chrisman Rd.-3 4mi.i South Of City Lot Size PM l—r—Y 835-4 51 Owner's Name .4 Edwards & Son Address 6352 W—Gana-1, Phone !��_" Contractor Hennings Bros. Address 3525 Pelandale M d- License No. 290 13 Phone_ - TYPE OF WELL/PUMP: NEW WELL XX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: .SEPTIC TANK 1001+ SEWER LINES DISPOSAL FLD. 100'i- PROP. LINE .+++.... FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n - i "Domestic/Private )UGravel Pack H Tracy Type of Casing Py Specifications 11 _ Specifications J M Public {-1 Other ❑ Delta' Depth of Grout Seal .00 Type of Grout-ell. e__ _ 1 I I Irrigation —Approx. Depth l driller __ I Eastern Surface Seal Installed by - , Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth P75 Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is, available within 200 feet.) o� Installation will slei'i : Aesidehce` k Commercial— Other fi r, N Number of living units: Number of bedrooms Character of o-ij to Ylde'pth of 3 feet: ''` Water'table depth SEPTIC TANK ❑ Type/Mfg {`' Capacity No. Compartments E PKG. TREATMENT PLT. ❑ Method of Disposal ,.. P Distance to nearest:s" Weil Foundation Property Line` i LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number. SUMPS ❑ Distance to nearest: Well Foundation Property Line L-m��a&PoSAL 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 Di§trict. 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 k 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 inspections. Complete drawing reverse si Signed X_Henn Inds Rros _ Titla. Date: - -g-� FOR DEP TMENT USE ONLY . 1 Application Accepted by4CAo%&_.L &an - Data Area Pit or Grout Inspection by Date Final Inspection by Date ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 RECEIVED BY DATE PERMIT"NO. j'� yMMy�� o.v x"75 YG]p dC�(Q \\n '4H 13-24,AEV.iiHSY �� O Q