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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AJ 1601 E. HAZELTON ON AVE., STOCKTON, CA %A 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 HealthDistrict. Job Address 28522 S. Airport. Way_ City Manteca Lot Size PM Owner's Name Maurice Roos Address 28522 S. Airport Way, Manteca Phone 823-5915 Contractor Hennings Bros. Address 3525 Pelandale, Mod, License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Q( DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES DISPOSAL FLD.1nn t PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 9n t PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom CX Manteca Dia. of Well Excavation 12" Dia. of Well Casing d )(1 Domestic/Private )(:] Gravel Pack ❑ Tracy Type of Casing �Vr Specifications F] Public F1 Oftler n Delta Depth of Grout Seal '11130 1 Type of Grout_3&t on it tZ _. I I Irrigation /7�Approx. Depth I I Eastern Surface Seal Installed by�driller Repair Work Done ❑ Type of Pump H.P. State Work Done_ N Well Destruction ❑ Well Diameter Sealing Material (top 501 OQ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (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 r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Metho¢alf Disposal } Distance to nearest: Well Foundation Property Linel J j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El1 Distance to nearest: Well Foundation Property Line ��+"` l98g SEEPAGE PITS I I Depth Size _ Number Yl SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 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. Complete drawing n r er side. Signed X Hennings Bros. By Title: .0 Date: 4-5-89 FOR DEPA TMENT USE ONLY I Application Accepted by Date_ � Area 141 Pit orrout spection by�j� Data S Fi al Inspe 'on 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., .0. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. + EEH H 13-24-24IREV.I/x5) —7Q w ®o 1?9 =7L13