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f ' `01 APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA pX4&ENT r Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) MAY 3119 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor�C gMtiTAis jV1Hn is made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rul�y�u ho #Ltd && Joaquin Local Health District. y ? -"� r Faq , CKG Job Address /C- -Lot 4i.� Country: Rd ' City Lot Size PM Owner's Name Po111b0. Re.aIty/Steve Or'.mon{khdress P-0. Box 805, Tracy Phone XSr Contractor ,WenningS Bros. Address 3525 Pelandale, Mod. License No, 290613 Phone 545—11 AS TYPE OF WELL/PUMP: NEW WELL k WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK._ 100' SEWER LINES DISPOSAL FLD._1(lf]t.s 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 - i i 31 Dia. of Well Casing ti L1(Domestic/Private IR Gravel Pack ❑ Tracy Type of Casing 5t1 PVC Specifications i Fl Public ❑ Other Cl Delta Depth of Grout Seal Type of,G_ rout BentOn it1? J I Irrigation _.-Approx. Depth I-I Eastern Surface Seal Installed by_.- -_ driller Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ' l - Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments _ PKG. TREATMENT PLT. El f9 of Disposal Distance to nearest: Well Foundation Property Line T-t Q I LEACHING LINE ❑ No. & Length of lines Total length/size ; FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS i I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line ,- - DISPOAL PONDS ❑ p a ; I herebycertifythat 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§t'rict. 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." "' f{ The applicant must call for all required inspections. Complete:drawing o reverse site. r _ Signed x_[lenllings Bros-. BY -. Titl L.L Date: 7-88 OR E MEN* USE ONLY [' Applicano�ccepted by Date d1_11?/Y—a 1�i Area Q t Pit CrG)rounspection by Date� " Final Inspection bydate Addmments: t /p''/ 3 r' S r0 v eo �✓� U/ 1� �h, � / I ❑ Stk 466.6781. - ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 66385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT OUE, AM/O�U�NT REMITTED CK RECEIVED BY DATE PERMIT NO. r EH 13-24(REV,1/rt 51 " + O ` D' [Y T r�..�F-1 � A 1�k ' EH 14-2B r 1 �E/ v`•� i