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5 - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVC., 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. Job Address 7035 SOI;th CoUrtry Rd- City Stockton Lot Size 246=X398' PM Owner's Name Omar de DeVel Address P.O. Box 1009, Tracy Phone 835-4949- Contractor HmniDgs BmsS Address.3525 Pelandale �est0 License No.29W13 Phorie W-1185 TYPE OF WELL/PUMP: NEW'WELOW WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100'+ SEWER LINES rr DISPOSAL FLD.100'+ PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL - _PITS_ /SUMPS . . .t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_211 Dia. of Well Casing 'I X1 Domestic/Private [)(Gravel Pack ❑ Tracy Type of Casing Pvc Specifications t'1 Public 71 Other ❑ Delta Depth of Grout Seal 5Qr Type of GroutR�tMJt�- _ I I irrigation R,&�Approx. Depth 11 Eastern Surface Seal Installed by, riri1Inv, Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑, Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is .available within 200 feet.) Installation will serve: Residence_ Commercial— Other r Number of living units: Number of bedrooms O Character of soil to a depth of 3 feet: WatQWn LV SEPTIC TANK ❑ Type/Mfg Capacity No. Ji PKG. TREATMENT PLT. ❑ Metho( of Disposal Distance to nearest: Well Foundation Property Line-APR 2 7. 989 LEACHING LINE ❑ No. & Length of lines Total length/size ¢ FILTER BED ❑ Distance to nearest: Well Foundation Property WwpONMENTAL HEALTH � SEEPAGE PITS 11 Depth Size Number j SUMPS ❑ Distance to nearest: Well Foundation Property Line T DISPOSAL PONDS D ` 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 s 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 n 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- . A tion laws of California." The applicant must call for all required inspections. Complete drawingn ve0eide. Signed X Hennings Bros. BY Title: Date: 4-24-89 } F. DEPARTMENT USE ONLY � •t Application Accepted by Date r Area74 Pit or rout 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 EEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. i INFO C � 1 +.EH 13-24(Rev,1 i n 51 EH 14-28 _ i