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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT r 1601 E. HAZEL 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 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. .lob Address 1750 W. Edna Ct. Lot 5 city Tracy Lot Size PM 3941 A Holly Dr. , Tracy 835--6921 Owner's Name J.D. Most Const. Address " ;�) 'a Phone Contractor Hennings Bros. Address 3525 Pelandale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL ER WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100, SEWER LINES DISPOSAL FLD. 100' 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 12r� Dia. of Well Casing fill EX Domestic/Private [X Gravel Pack IN Tracy Type of Casing Specifications .� I"] Public (_1 Other ❑ Delta Depth of Grout Seal Oil t Type of Grout RantQrl i t _ J I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by dri 1 1 er Repair Work Done U 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 I REPAIR/ADDITION 1 l DESTRUCTION 1 I 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 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ 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, 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 sh employ persons subject to workman's compensa- tion laws of California." The applicant must call for afl required inspections. Complete drawing on verse si e. Signed X Hennings Bros. By Title: Date: 3-14-90 RD AR ENT USE ONLY r Application Accepted by Date _ Area Pit or Grout Inspection by Date Final Inspection by Date 3 23 ,I rr Additional Comments: C o T 4-a 110 ❑ Stk 466-6781 © Lodi 36923621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Ret rn all copies to: Environmental Health P/e_rmit/Services /1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 5r2r FEE AMOUNT DUE AMOUNT REMITTED K INFO H RECEIVED BY PATE PERMIT NO. `♦ EH13-24MEV.t/R5) t � 'Al 2-3 EH 1426 l