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1 ,0t, PAYMENT APPLICATION FOR PERMIT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 2 51968 1601 E. HAZELTON AVE., STOCKTON, CA MAY Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH PERMkT f SERVICES (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. FornaScero Estates I Job Address Lot 1 Fairoaks. Rd CityTri Lot Size PM Owner's Name Address Phone 474-9922 Contractor H�'nn1�5 Bros. Address p3 p e License No. —Phone – 11 R5 TYPE OF WELL/PUMP: NEW WELLWELL REPLACEMENT 0 DESTRUCTION PUMP INSTALLATION ?00' SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES DISPOSAL FLD. 1001-_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS li 1:1Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation it Dia. of Well Casing LX Domestic/Private �)(Gravel Pack AX Tracy Type of Casing C Specifications F1 Public ❑ Other M Delta Depth of Grout Seal 'ITnn,,_1 Type of Grout R�n}n�ite__. 1 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by dr- or 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 l 1 REPAIRIADDITION I I DESTRUCTION I 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:r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.-0 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 I 1 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." Contractors 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 drawing on reverse side. Signed X Hennings Bros-. ' Title: Date: 5-23-88 FOR DEPARTMENT USE ONLY Application Accepted by , r Date J r Area Pit or Grout Inspection by ,C Date r inal Inspection by Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 a FEE AMOUNT DUE AMOUNT REMITTER C RECEIVED BY DATE PERMIT'NO. INFO �'�h7�� /�'1 ��1p�� �.EH 13-24 IpEV.i i H 51 U� e7 , m o�y EH 11-28