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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT T 1601 E. HAZE T ON AVE., STOCKTON, CA AY MEN Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) MA� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This a I" triAgIH made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regttjvl►0�� i `aAS Local Health District. t�pE�M1 (S1LJ6�SO t Two River Rd. Job Address 6625 Ave D, N.W corner of Ave, n R city- Man Lot Size PM - Owner's Name Roos & De Riuyter Inc _ Address 6625 Ave. D__,_Manteca---- Phone 823- a 3 Contractor yenninaS Bros. Address 35 25 P,21anda1P, MoId__License No.___2C Phone TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT( DESTRUCTION ❑ fy)��l�c�� PUMP INSTALLATION El SYSTEM REPAIR 11 OTHER El / L IIIA u DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES _ DISPOSAL FLD._a..40!.f-PROP. LINE FOUNDATION _ AGRICULTURE WELL ___ OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Weli Excavation9 11 irT Dia. of Well Casing XX Domestic/Private UGravel Pack C7 Tracy Type of Casing-- P1112 Specifications (� ['I Public F] Other i I Delta Depth of Grout Seal/L( /zType of Grout_�eXLtQI1] te__ I I Irrigation � Approx. Depth I I Eastern Surface Seal installed by Driller Repair Work Done ❑ Type of Pump —_.__—_ H.P. ________ State Work Done Well Destruction ❑ Well Diameter Sealir:g Material (top 501 Depth _ _._ -iiler Material (Below 50') _ -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1 , I.i ry/,;.DITION I I DESTRUCTION 1 1 (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— ___ Fc.undation Property Line SEEPAGE PITS I I Depth ___Si,-e Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ _ I hereby certify that I have prepared this application and that the work v-.,iii i,e 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. Completa drawing on reversee/si e. , Signed X HenningS SroS. _ ByTitle: ''s j" a` v f{ �_- t Date: 5-23-88 !^ FOR DEPARTMENT USE ONLY Application Accepted by '! ' .�C-t,E:� -- , Date. !► Area_ 1 Pit or Grout Inspection by� r7— Z�"Z_ � d Final Inspection by Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. + EH13-24(REV.i i n 5) 2! ,j' a�f -•W t/ ll1` �u C ^/ (�i EH 14-26 V