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APPLICATION FOR PERM IT SAN JOAQUIN LOCAL HEALTH DISTRICT pAY "HT 1601 E. HAZE'ON AVE., STOCKTON, CA RFCEIVFD Telephone {20 466-6781 PERMIT EXPIRES 11,YEAR FROM DATE ISSUED MA� (Complete in Triplicate) gNVtRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t e woi{q{ i�i� his application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rul ana ulations of the San Joaquin Local Health District. .lob Address 25969 COrraL-Hol low Rd. City Tracy Lot size 2001 X3501 pM Owner's Name Jeff Skelton Address 25969, Corral .Hollow, Tracy Phone 836-1218 i Contractor Hennings Bros-: Address 3525 Relandale, Mod: License No, 290813 Phone 545-1185 TYPE OF.WELL/PUMP: :NEW WELL LX -S . WELL REPLACEMENT C] DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150 t SEWER LINES DISPOSAL FLD. 1501'} PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 150 t-1- '- ---� INTENDED USE _. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -- Ij Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of Well Casing tr LX Domestic/Private IN Gravel Pack DO Tracy Type of Casing pyC - Specifications I`i Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout_3Entnn i tp I i Irrigation Approx. Depth I 1 Eastern Surface Seal installed by dri 1 ler 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 I:] REPAIR/ADDITION I ] DESTRUCTION I 1 (No septic system permitted if public sewer is LA available within 200 feet.! JU 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. U tst Method'oU Disposal Distance to nearest: Well Foundation Property'Line LEACHING LINE Cl No. & Length of lines Total length/size n FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well' Foundation Property Line -- —,,DISP_OSAL RANDS_–,_,-❑' __A *- , �. -_ I hereby certify that I have prepared this application and that the work will be done in accordance with Sian 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. 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 inspections. Complete drawing on re erse side. Signed x_. Hennings Bros.. By — Title: _ rlL ,1_h d Date: 58-89 • -- DPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by �"'� Date Final Inspection by Date /I Additional Comments: '- �- o S+ R'��/� J�/ /!¢ B/�/ / / �Z I 0 Stk 466-6781 0 Lodi 369-3621 L7 Manteca 623-7104 ❑ Tracy 835-6385 A ti nt- pi rn all co res to: Env'o ental alth Permit/Services 1 1 E. Hazelto Av P. Bax 2009,-, GA-952 l- _ –/– j 7 1 - F FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. INFO � _ +.EH 13-24(REV.rias) EH 14-2e �,t a 002 !�/.�� /O�C- �Ti� �Y ��,yt ��.sf�t ✓c¢-r�os S �/+r�' �f.Lp !D�"' �.✓uu�`"`�' /A 3� y ! G.CJ