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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 . SCANNEDPERMIT 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 5469 E. DIVISION R D. city M A N T E C A Lot Size PM owner's Name RAY GREEN Address 5469 E.. DIVISION R D. Phone 239-4696 Contractor HENNINGS BROS. DRILL Address 3525 PELANDALE AVE -License No. 290813 Phone_545-1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT)}( DESTRUCTION}([( PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ —DISTANCE TO-NEAREST: SEPTIC-TANK _ DO t -SEW,ER.LINES._80 r DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONST ❑ Industrial ❑ Open Bottom )O(Manteca Dia. of Weil Excavation Dia—of Well Casing OYrI 11 HDomestic/Private IX Gtavel Pack ❑ Tracy Type of Casing PVC Specifications 1'1 Public n Ot er Ll Delta Depth of Grout Seal 'Y 51, + Type of Grout B E N.T ON I T E I I Irrigation /-'—� -Approx. Depth l I Eastern Surface Seal Installed by HENNINGS BROS. DRILLING C Repair Work Done U Type of Pump H.P. State Work Done `s Well Destruction [A Well Diameter 6 11 Sealing Material (top 50') BENTONITE Depthcaye{—in at 301 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION ( I (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 i C LEACHING LINE 0 No. & Length of lines Total length/size e i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number - SUMPS 4.mc Llin—Distance-to-nearest: Well= s Foundation.. — Property Line DISPOSAL PONDS ❑ 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 DiMrict. 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 I 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,d_lrAwing on reverse side. Signed X t Title: Date: FOR DEPARTMENT USE ONLY m 4:9n ' Application Accepted by Date Area Pit orGrout spection by / Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man 823-7104:* ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental HealthhPPermit/Services 1601 E. Hazelton Ave..,, P.O. Box 2009, Stk., CA 95201 FEE AMOU E AMOUNT REMI D RECEIVED BY DAT PERMIT NO. INFO + EH 13-24 1 HFv.i/a 5) y\ ' 1 EH 14.20T%q