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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAY)'WEN-r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, .PHONE (209)468-3420 RECEIVED P O BOX 2009, .STOCKTON, CA 95201 S E P 2 4 1992 Sr"it !OAQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P0BUC HEALTH SERVICES � r.","VI ,L�;VNIFNTAL HEAL I f DIVISION (co .Triplicate} . Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. 28104 BIRD RD. Job Address — _ _ __ City "TRACY Lot Size/Acreage Owner's Name MARLENE HENDERSHOTT Address 28104 BIRD RD. Phone 836-2100 ContractorHENNINGS BROS. DRILL. Address 3525 P"ELANDALE AVE-License No. 290813 Phone 545--1185 TYPE OF WELL/PUMP; NEW WELL I WELL.REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 10 0 r SEWER LINES 100 , DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial 0 Open Bottom O Manteca Dia. of Well Excavation 12 Tr Dia. of Wait Casing rr CX Domestic/Private Gravel Pack X Tracy Type of Casing._ PVC Specifications l Il Public 1-1 Other I-1 Delta Depth of Grout Seal 100 , Type of Grout 10 N I I Irrigation ._,....Approx. Depth 11 Eastern Surface Seal Installed by HENN I NGS - BRaS_ DRILLING C O. e k Repair Work Done U Type of Pump H.P. Stats Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth cl� �^ r:s Depth: Filler Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I INa septic system permitted if public sewer is available within 200 feet.) Installation will server" 'Residence '_ Commercial Other i.r r: %}` "7 Number of living units: Number of bedrooms Chracterjpf'solV�to 41 depthTof 3 feet: Water table depth ' SEPTIC+TANK C1 Type/Mfg -Capacity No. Compartents i " PKG. TREATMENT PLT ❑ Method of Disposal Distance to neaea rest. Welf Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 6 R SEEPAGE PITS I I Depth Size Number n .j 7;,1 r C - —. _SUMPS 0 Distance to neareet:,: Well - .Foundation - -----_rPropertjr,Line DISPOSAL PONDS O 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 County I 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 I certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." y The applica t must call for all required inspections. Complete drawing on reverse side. Signed A Title: Date: S E P T. 2 3 , 19 9 2 FOR DEPARTMEN USE ONLY Application Accepted by + Date ¢ Area �4 Pit or Grout Inspection by nate ! Final Inapecdon by Date - 16 Additional Comments: Applicant - ReVirn all copies to: San Joaquin County Public Health Services - Q�fCt kW/ Environmental Health Permit/Services /. 445 N San Joaquin, P a Box 2009, St;kn, CA 95201 > q0 Z11FEE C� + S f INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. EH 14-26(REV.rixsl L(,d � � - V i�� Lf 6� i G•-y T `2-3U -