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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. 18621 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 7730 W• V A LP I C O R D. City T R A C Y Lot Size PM Owner's Name- DELTA D E V . JC O. . Address'P O. BOX 7414 S T O C K T O N Phone 931 -0343 f f ContractorHENNINGS BROS.: DRWess - 3525 PELANDALE AVE. License No. 290813 Phone 545- 1185 TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST- SEPTIC TANK. 1001 SEWER LINES 1001 DISPOSAL FLD.-- '- PROP: LINE { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE < TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial Ll Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing 6" X1 Domestic/Private Gravel Pack )`7 Tracy Type of Casing PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1 0 0 1 Type of Grout BENTONITE ❑ Irrigation Approxi Depth ❑ Eastern Surface Seal Installed by H E N N.I N G S BROS. DRILLING CO Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t Fifler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,J � available within 200 feet.) W Installation will serve:n Residence Commercial Other Number of living units: Number of bedrooms Character of soil,to a depth;of 3 feet ;. a rt E :�` Water table depth ., r i _ I SEPTIC TANK ❑ Type/Mfg Capacity; No. Compartments PKG. TREATMENT PLT:_❑. -s MetFfodof Disposal t 7 a 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 k `SEEPAGE PITS ❑ Depth p Size Number SUMPS �.. ❑ .Distance to nearest:. Well Foundation Property Line r DISPOSAL PONDS ❑ is I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance's; state;laws, and rules and regulations of the San Joaquin Local Health District. `+ A . .y 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 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." r The applicant must call for all required inspections. Complete dr wing on reverse side. ;t Signed - y -tie: A S S I T. MANAGER date: 12'-2 9-8 6 '' i w ...— 3 FOR DEPARTMENT USE ONLY - Application Accepted by Date t2 '�"Arear Pit or Grout Inspection by ! Date Final Inspection by Date . ! 7 Additional Comments: ! `+ `) ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 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 CASH RECEIVED BY DATE PERMIT"NO. t IZ +SEH 13-24(REV.7/951 EH W29 j'1b1I3 �� ate--