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;.rry APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 MIAR 0 8 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OUNTY (Complete in Triplicate) PUBLICH E �ILT IIN I' ii ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tffE+4ir ��4`it} n 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 1707 Edna Court Lot #9 City Tracy Lot size 230'x262' PM Owner's Name G.E. Whitlock Const. Address 1131 Marian Court, Trac Phone 835-6338 Contractor Hennings Bros. Address 3525 Pelandale, Mod/. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL CA WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES DISPOSAL FLO. 1_00.'FPROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Il Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing R Domestic/Private R Gravel Pack k7 Tracy Type of Casing PUC Specifications F1 Public H Other 17 Delta Depth of Grout Seal 100' Type of Grout-Bentonite—_ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by drl l f pr Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction © Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') —_ TYI`E OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:.!Residence= Commercial=^Other G 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.1❑ .' " '' Method of Disposal Distance to nearest: v Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS El 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 Di§trict. 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 amploy persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing o averse side. Signed X nn s B120s y Title: Date: —7-90 FOR DEPA ME USE ONLY q� Application Accepted by �� Date� `D Area Pit or Grout Inspection by Date Final Inspection by Date �3 �f0 Additional Comments: 110 IT 8-7-123 p—1'23 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82 -7104 0 Tracy 835 5 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 CK 01 RECEIVED BY DATE PERMIT'NO. INFO Cwn + EH13-24 1REV.5/Hsi EH 1428