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APPLICATION FOR PERMIT QQ SAN JOAQUIN LOCAL HEALTH DISTRICT RECIVE � 4,3&Cl 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 J U L 16 19090 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NV�RONMEN TAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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. Job Address 1009 AVALON DR. City STOCKTON Lot Size PM Owner's Name LEO JOHNSON Address 1009 AVALON DR. Phone 931 -0829 Contractor HENNINGS BROS. DRILL Address 3525 PELANDALE AVE. License No. 290813 Phone 545-1 185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 65 ' SEWER LINES 651 + DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-J-5 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of Well Casing 611 X1 Domestic/Private (Gravel Pack ❑ Tracy Type of Casing PVC I Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of GroutBFNTONTTF ___ i I Irrigation —_Approx. Depth I I Eastern Surface Seal Installed by HENNINGS BROS . DRILLING C O_ Repair Work Done ❑ Type of Pump H.P. State Work-Done_ Well Destruction X Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION t 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 I Depth Size Number �1 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 required inspections. Complete (�draawiinng on reverse side. Q Signed X Af m��retl!-m �iti (�3, `owl `y Title: cr� Sy 17erN r 5 e,� Date: z` f F R DEPARTMENT USE ONLY Application Accepted by /Date —gs- �Q Area Pit or Grout Inspection by �'J Dat-e-(/ S Final Inspection by ,�/ ,,,Daate J 1 e Additional Comments: � 1`� L �JJ�' C✓Lll 'fr'r�N /V��!/ ��.(fo��0 /�i/U��iC��"< GY 7�°T`� O Stk 466-6781 O Lodi 369-3621 n Mant ca 823-7 Tracy 835-6385 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 ^CASH f EH13-24(REV.)i n 5) EH 14-28 �/ 0 (Itl-)9/9