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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 J fit, t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) .ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hP"py J%�j�h ,pplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welilpump and the Rules and Regul tions of ti`i6 San Joaquin LocaE Health District. �� east ide Job Address __ 581 Amy Ct.-.4mi 1p SolIt.h of Wyman Rd- _ City Lot size 2.40 acres PM r Owner's Name - Tubbs & Sons Electric . Address 401- N.- Main,..Manter.a Phone 239-1�g7 Contractor HenningS Bros. Address 3525 Pelandale, Mod/. License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL)(X WELL REPLACEMENT El DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR 71 OTHER F DISTANCE TO NEAREST: SEPTIC TANK 110, SEWER LINES DISPOSAL FLO._110 4=6 PROP. LINE FOUNDATION __ AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial CI Open Bottom EX, Manteca Manteca Dia. of Weil Excavation 1211 Dia. of Well Casing _ XX Domestic/Private XX Gravel Pack Tracy Type of Casing P /Specifications Public fa Other i 1 Delta Depth of Grout SealType of Grout_Be_nton i to I ! Irngation Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done i 1 Type of Pump H,P. State Work Done Well Destruction I.' Well Diameter Sealing Material {top 50') Depth Filler Material (Below 50'I �- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i ; DESTRUCTION € i (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence____, Commercial Other - Number of living units: Number of bedrooms_ 1 Character of soil to a depth of 3 feet: _._ Water table depth r SEPTIC TANK ❑ TypelMfg Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line C LEACHING LINE 17 No. & Length of lines Total length/size FILTER BED 11 Distance to nearest: WL-11 Foundation _.-- Property Line SEEPAGE PITS I 1 Depth Size,w— Number _ SUMPS ( 1 Distance to nearest: Well Foundation _ ._. Property Line DISPOSAL PONDS 11 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 tali for all required inspections. Complete drawing on reverse side. Signed X Hennings Bros. By 9 Title: Date; 8-1-90 Application Accepted by F=T USE ONLY Date Area / J Pit or Grout Inspection by Date --le t Final Inspection by (_ C� G Date Additional Comments: G ,Z,1,e ' �O C1. S — ❑ Stk 466-6781 O Lodi 3621 El Manteca 623-7104 E Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O, Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT N0. + EH 13-24(REV.i/a5) Y1C }f C EH 14-28 tcc)