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— N APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) DEC 2 1988 Application is-hereby made.to the San Joaquin Local Health District for a permit to construct and/or install th 4 herein described. This application is made in compliance iivith-San Joaquin CbuntyOrdiriance;No.549 for;sowage or No. 1862 for well/.pump and thm" J" Joaquin II Local Health PFRMlT,�SE1tV(CES Job Address' 7103 COuntr 'R Lot #4 City_St r__ _ktnrt Lot Size�dF,l sr�4f� PM S25-49 9 Owner's Name ' 'S1;eVe Orm Address Phone Contractor NeI1111I1CJS=$ro5. "r Address 3525 Pelandale MOd License No. 290813 _Phone — TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO_NEAR EST:.SEPTIC TANK , U]D f SEWER LINES DISPOSAL FLD. I-0g_f_._ PROP. LINE ¢ FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LlIndustrial - L1Open Bottom 1:1Manteca Dia. of Well Excavation Dia. of Well Casing 6 It EX Domestic/Private A Gravel Pack ❑ Tracy Type of Casing PVC. Specifications " rl Public 171 Other * Ll Delta Depth of Grout Seal .psi]{ Type of Grout r I I irrigation --Approx. Depth l I Eastern . Surface Seal Installed by _ Ci l^1 1 1 Pl^ 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 1 REPAIR/ADDITION l 1 DESTRUCTION l 1 INo septic system permitted if public sewer is — available within 200 feet.I Installation will serve:, Residence — Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth rr I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Y t 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 I 1 Depth Size Number SUMPS Ll 'Distance to nearest: Well . ;Foundation mm Property Line r DISPOSAL PONDS ❑ k 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 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: "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 a revers rde. ; Signed X Hennings Bros. BY Data: 11-30-88 FOR DEPA TMENT USE ONLY Application Accepted by _.._ _ Date Z G Area Pit or Grout inspection by Date n—2-343— Final Inspection by Date Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca- 823-7104 ❑ Tracy `835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ;PERMIT'NO. INFO CASH . EH 13-24(REV.tins/ EH 14-28 v' „�