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& a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 41601 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 tn.th hI Health District for a permit to construct and/or install the work herein described. This application is made in complian i i , het Ordinance No. 549 for sewage or No, 186 for well/pump and the Rules and Regulations of the San Joaquin Local Health Dist��C�y,A�� mai Job Address -5 68Y Ct.-.4mile south of Wyman Rd, east std � 2 City Lot Size .40 acres pM Owner's Name _ -. Tubbs & Sons ElectriC Address 401 N. Maur, Manteca Phone 239-1397 Contractor kennings Bros. Address 3525 Pelandale, Mod. License No. 290813 Phone 545-1185 TYPE OF WELL!PUMP: NEW WELL XX WELL REPLACEMENT ❑ DESTRUCTION i r PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER Il DISTANCE TO NEAREST_ SEPTIC TANK 120 t SEWER LINES DISPOSAL FLD._=t r PROP. LINE FOUNDATION _ AGRICULTURE WELL — OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial C Open Bottom Manteca Dia. of Well Excavation 6 n �/ � Dia. of Well Casing . X, Domestic/Private I-(Gravel Pack ] Tracy Type of Casing PVC Yp 9 � Specifications I". Public r Other I-1 Delta Depth of Grout Seal _ � Type of Grout Bentonite_ I I Irrigation Approx. Depth Eastern Surface Seal Installed by drl l ler Repair Work Done 11 Type of Pump H.P. _ State Work Done _ Well Destruction E Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 50'I TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIR/ADDITION t 1 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: Water table depth SEPTIC TANK 1-1 Typel Mfg Capacity No. Compartments PKG, TREATMENT PLT. C7 Method of Disposal Proper , Distance to nearest: Well Foundation -. ty Line _ LEACHING LINE 1-1 No. & Length of lines �— �- - Total length/size _ FILTER BED 1-1 Distance to nearest: Well__ Foundation Property Line SEEPAGE PITS 1 1 Depth —_ _Size Number SUMPS Lj Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS I.] 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re uired inspections.pections- Complete drawing on reverse side. - Signed x_ Hennings Bros. By 8-1-90 _ Title: _-� Date: F DEPARTIMRENT USE ONLY Application Accepted by c -g Date / Area Pit or Grout Inspection�[� Locli Date Final Inspection by - __ Date Additional Comments: Cl Stk 466-6781 369 621 EJ Manteca 823-7104 Q Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24 1REV.1/4 5i EH 14-2e ��0