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APPLICATION FOR PERMIT 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 compiiance 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 D�stnc; ttr e f�'•s�'e z `g5� , ,w�,�,��3 tir q��°7� d� ��`i s� c �,�i Job Address " X7855#W U;a 1;�1 co f Rd . , �� , . .+ _ city Traci Lot size 266'x492' PM Owner's Name DOMO' Construction: '• Address .8961 Almendra, Traci Phone Fn5_2q2.9 Contractor Hennin S Bros. Address 3625 Pelandale, Mod, License No._290313 Phone .54-5-1185 TYPE OF WELL/PUMP.: NEW WELL EX -WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1QQ!�- SEWER LINES DISPOSAL FL❑. lno+ . PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1211 _ Dia. of Well Casing 6 rr IX Domestic/Private A Gravel Pack Tracy Type of Casing PVC Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal �Q[}_!.__ Type of Grout RantOpj t� I I Irrigation _-Approx; Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter ' Sealing Material [top 50'1 r�� �~ VL • • Depth � Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I'] DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) E '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 SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments PKG. TREATMENT PLT. ❑ t ,, Method of Disposal (1 Distance to nearest: Well Foundation Property Line (�`4 LEACHING LINE ❑ No. & Length of lines Y Total length/size c FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth f Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS -❑ 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 ail required inspections. Complete drawing revers side. R 7 Signed X HennincI5 Bros, Titl7 Date: �} FOR DEPA TMENT USE ONLY 9�c !` �► (� Application Accepted by Date �' a Pit Grou ns ction b pe Date Final Inspection by ate B tmt� Additional Comments: SF� ti ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7;04 ❑ Tracy 835-6385_ tea&–d al.ckvAvj Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 CK 41 FEE INFO AMOUNT DUE .1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I +.EH13-2,IREV.,,H51 OLI331 111151 Q-Yf "log EH EH 1426