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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 P a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pUe��oAQW4 1 �d (Complete in Triplicate) NV�R�N �Ekr Cli F+Vr, �� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein derr[9e�(�MQ]SF r y n is md[ielin coriipliancd with Sandi oaquin County Ordinance lllo f549 for sewage or No. 1862 for well/pump and the Rules and Regulations of tT, S�Q�W AIV ll L&al;Health Job Address 622 N:= Windsdr'' r'. ;44 City Stockton Lot Size MON' PM Owner's Name Abdul Karin Address 622 N. Windsor Stockton Phone 462-2534 Contractor; Hennings Bros. Address 3525 Pelandale, Mod. License No.290813 Phone 545-1185 TYPE OF WELLIPUMP: NEW WELL I WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-2Q PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS EJ Industrial (71Open Bottom ❑ Manteca Dia. of Well Excavation 1?" Dia. of Well Casing 6° CX Domestic l Private LX Gravel Pack ❑ Tracy Type of Casing PVC Specifications M Public f 1 Other 171 Delta Depth of Grout Seal Type of Grout Benton lte - i I I Irrigation __.Approx. Depth I 1 Eastern Surface Seal Installed by Dri)ler Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below.,50') — TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll 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. J 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." The applicant must call for all required inspections omplete drawing on everse side. Hennings Bros. By 9-21-90 t Signed X Title: Date: f OR DEPARTMENT US ONLY / // Application Accepted by Dater� = Area # Pit or Grout Inspection by _ Date Final Inspection by "`' Date 41,44 to Additional Comments: D"&_ r / 3 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M nteca 823-7104 ❑ racy 5-6385 A li nt Rpturn all copies fq� Env ronmen I Heal ermit/Services 1601 E. azelton Ave., P.O. Boxes, St CA 95201 , Q� 1f.r!!1 rl1l�Sw�1.G� %`�L�' j0l i� fO FEEkA7MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �^ (1 }�4t� t•1� +,EH 13-24/REV.t i n 51 ��i 1 r� .�...� O b'7() + .�.. .* EH 114-26 7t- ,dE�° 3lSb—' c.3J, 'G1�7 yer t _