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e, '~ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., 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,S,an.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.< F 1(20 , Edna Ct. City Trac Lot Size 207'x314_' PM Job Address Contrail9l Marian C T X Phone 835-6338 Owner's Name TOM Brown/George WhitIOCkAddress Contractor Hennings Bros. Address 3525 Pelandale Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 1 SEWER LINES DISPOSAL FLO.10O PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. i f Well Casing Type of Casin PVC Specifications XX Domestic/Private CX Gravel Pack � Tracy 9 l"1 Public ❑ Other ❑ Delta Depth of Grout Seal 1001 Type of Grout 1 1 Irrigation __-Approx. Depth l 1 Eastern Surface Seal Installed by dri - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material {Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo 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 Q 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 1 1 Depth Size Number SUMPS D Distance to nearest: Well 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 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Califo i-a Contractor's hiring or sub-contracting signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, ["shall a loy persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawin rev rse e. Hennings Bros. By Ti Date: 11-5-90 Signed X F R DEPA NT USE ONL Application Accepted by date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 3 7 , A.+4 ❑ Stk 466-6781 ❑ Lodi 369-3621 b 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 96201 FEE AMOUNT DUE AMOUNT REMITTED C 3H RECEIVED BY DATE PERMIT'NO. INFO + EH 1324(REV.1/H 5) EH 14-28