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w 4- APPLICATION FOR PERMIT le SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601'E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED~ II (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 incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1861 for well/pump and the Rules and Regulations of the San Joaquin Locale Health District.' Job Address 3 '' 32-989 C H R I S M A N .R D. City TRACY Lot Size PM Owner's Name EMIL BERNARD0 Address 418 NASSAU LN . - HAYW00D CAPhone C415J 485-7863 Contractor HENNINGS .L.EROS.. _D R I LL.Address -3 5 5 P . License-No.=-29.0.81-3"--Phone = TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation 1 2 11 Dia. of Well Casing 11 ; (X Domestic/Private KI Gravel Pack CQ Tracy Type of Casing PUC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 100 ' Type of Grout BENTONITE ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by HENNINGS BROS. DRILLING CO. IN Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth _ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 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 ❑ DepthSize Number SUMPS ✓ ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a. 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 { empioy 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: "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 CaMornia." V The applicant must call for all required inspections. Complete,di{kyyw'nng on reverse side. Signed X Title: /�.5 ��e CO-IN0-C1I'-V_ Date: �n' i�` g� FOR DEPARTMENT USE ONLY `l 0's f Application Accepted by Date Area Pito Grout spection ' -F'� c'r" °�ate� Final Inspection by Date F Additional Comments: ( � -'- �'- -7- 0 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AM NT REMITTED SH RECEIVED BY DATE PERMIT'NO. INFO ;. - 6_PCO + EH 13-24 1REV.+/a 5) 7o EH 14-28 '