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eK APPLICATION FOR PERM . APP IT _ �SAN JOAQUIN FOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telepho'he (209) 466-6781 PERMIT EXPIRES TYEAR 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 oaquin Go, ntyjordinance-No 549;for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made'.in compliance with;S an J Local Health"Distract ,�,a t �41 i r ; „ y �r PM 3 17554 W...,. Byron Rd.= _ cit �Y _ Lot Site Job Address 221 no c 11{aflj ee Ir"* Phone owner's Name DdlnOn POmbO Address " " � '- Contractor Hennin S Bros Address H25 PP]andalP. Mod-_ License No._—zgL0BJ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ - OTHER ❑ PUMP INSTALLATION ❑ IR3pROP. LINE �Sf t SEWER_LINES DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK - PITSISUMPS - FOUNDATION AGRICULTUREWELL - -OTHER WELL _ _ — INTENDED USE TYPE OF WELL PROBLEM AREA Ski CONSTRUCTION SPECIFICATIONS,..., t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of iNe11 Excavation r' Dia. of We11 Casing r' Tracy ti T�ype'of Casing' i Specifications �DomesticlPrivate"' XD Gravel Pack Type of Grout�E' M Public �. r pOytter CI Delta Depth of Grout Seal I I Irrigation O.Approx. Depth I 1 Eastern -Surface Seal Installed by "H•P. State Work Done Repair Work Done ❑ Type of Pump ` ¢' Well Destruction ❑, Well Diameter - Sealing Material (top 501 t M Filler aerial (Below 50'1 Depth f A TYPE OF%SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I 1 DESTRUCTION I l availablec system within200 feetitted if public sewer is `t nil Installation will serve: Residences Commercial, Other . . Number of living units: Number of bedrooms Water table depth Character of sail to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg • - Method of Disposal PKG. TREATMENT PLT. ❑ 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 1 1 Depth Size Number ❑: `Distance-to nearest:• �Well" _ - .�Fnundation ----- - ::Property._Line- v -_ �- - =. - -SUMPS- - - T� 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. Home owner or licensed agent's sigoature 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 n 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 shat!employ persons subject to workman's compensa- t tion laws of California." The applicant must call for all required inspections. Complete drawin n averse s e. Signed X HenningS Bros. By Tit Date: 8'7'88 R DEPA MENT USE 7/ Date Application Accepted by e- Pit or Grout Ins ction by Date 'C Final Inspection by ->= ''-✓� i _. "' �` �%E/�Y-,� Additional Comments: ' 85 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 95201 �f 170 SCI. Applicant - Return`all copies to: Environmental Health Permit/Services 1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA Cl— Applicant 3 r2/'7165�. I�er�.� t t!s/�Ci+ f -{roi 1'jru.cy=i.v�. A-/ -lq ry c..a6l 1-7o FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'NO. c3� 310 Ja4 INFO rf' -f+ _, 3Lo_335-b 1 a.EH 1324(REV.I H 5) �•� �� 01 EH 1428