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x APPLICATION FOR PERMIT yt - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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: " Job Address 322 1 0 `S: B E V E S City V E R N A L I S Lot size PM Owner's Name GENE- WAINWRIGHT CON�Jd1ss R.O. BOX 58, HUGHSON,CA Phone 538-4560 Contractor KENNINGS RLS_ DRi/ I Address 352.5 PEJ ANDALF AVF_ License No. 290813__Phone 54 5-1 185 TYPE OF WELL/PUMP: NEW WELL TR WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK 10 0 SEWER LINES 100 ' _DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/SUMPS - INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1.2 Dia. of Well Casing 611 IN Domestic/Private Gravel Pack ❑.Tracy Type of Casing PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout BENTON I T E ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seat Installed byINC Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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-wdepth.of 3:feet, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT RLT..❑,. ; . 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 ❑ Depth Size Number SUMPS 0„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. .' ,.1': " , "j, ' `! 3 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor#,.hitirtg.or pub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ perso jAi to workfoan's compensa- tion laws of California." *' .4 The applicant must call for all requir inspections. Complete drawing on reverse side. `=•- Signed x ;�° _ Y — Title.• ' A S S I T. MANAGER Date• 1 5 8 -- F R DEPARTMENT USE ONLY Application Acceptedy Date A Area;' 7= Pit or Grout Ins" ction b _� 1V Pe Y ate mal Inspection by D >; ... Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIV NO. + EH13-24(REV,1/a5) t A EH 14-26 !(n C� ' - k