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w ;f APPLICATION FOR PERMIT �• II SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZEL T ON AVE., ST.00KTON, CA � L 1� Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /9Z� II � � (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/pu p and the Rules and Regulations of a San Joaquin Local Health District. 0� � I' / �rli I .W. corner of Milton Rd. & Escalon- Bellota�H Job Address City �'�._-_ Lot Size PM Owner's Name Edward Rainey Address 76 Palm Dr. , Union Cit Phone415-489-2275 I Contractor Hennings Bros. Address3525 Pelandale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: it NEW WELL j{ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES, DISPOSAL FLD. PROP. LINE � ; - -- - FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPSY_ ' f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LlOpen Bottom L) Manteca Dia. of Well Excavation 14 mm Oia. of Well Casing 811- UDomestic/Private U Gravel Pack ❑ Tracy Type of Casing PVC Specifications 11 Public ❑ Other /�/ ❑ Dela Depth of Grout Seal /J�lS� Type of Grout Bentonite d I I Irrigation _Appro epth �I Eastern Surface Seal Installed by driller _ Repair Work Done D Type;of Pump H.P. State Work Done_ Well Destruction L1 Weil Diameter Sealing Material Itop 501 ry Depth Filler Material.(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION l I Wo septic system permitted if public sewer is I II available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms { - y Character of soil to a depth of 3'feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ii Method of Disposal Distance to nearest: Well Foundation Property Line i ij LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Numberc`- AUMPS __. ❑ Distance to_nearesC.—.Well .— rF,oundation —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 t 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 shall employ persons subject to workman's compensa- tion laws of California.' The applicant must call for all required inspections. Complete drawin reverse sid li 7-2596 Signed X Hennings Bras. By Titl Date: ORD f1AENT USE ONLY Application Accepted by Date Area Pito Grout nspection b "r Date f Final Inspection by Date I A P1 k Additional Comments: (�► �� — T/�� r /f ��'3 . ❑ Stk 466-6781 ❑ Lodi Ij369-3621 D Manteca 823-7104 ❑ Tracy 83F4&385 f/*v Av— `y 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 RECEIVED BY DATE PERMIT NO. INFO p +.EH13.24 1REV.$/Hsi I� - EH 1426 `l