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L `"` ,,,_�. APPLICATION FOR PERMIT �- SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZEL T ON AVE., STOCKTON, CA ►'.� _ Telephone (209) 466-6781 R>1r CF 's 41 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VSD' 4 (Complete in Triplicate) A� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hfi �fl� _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 R , 6 Joaquin Local Health District. r 11IXIVjC,9Lr� r. r Job Address 8411 W. Rinauro Ct. City Tracy Lot Size 215.'_X 289 PM Owner's Name George E. Whitlock Address 1131 Marian Ct. , Tracy Phone 835-6338 ` Contractor Hennings Bros. Address 3525 Pelandale, MOdeStOLicense No. 290813 Phone_545-1185 TYPE OF WELLIPUMP: NEW WELL IAX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK 1001; SEWER LINES DISPOSAL FLD.1001+ PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS- INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Domestic/Private I Gravel Pack M Tracy Type of Casing PUO Specifications M Public i=l Other ❑ Delta Depth of Grout Seal 1001 Type of GroutBentOnite I I Irrigation __Approx.-Depth I I Eastern Surface Seal Installed by driller M Repair Work done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material lBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I 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 4 Character of soil to a depth of 3 feet:^ Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS (_I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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." Contractors 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." i The applicant must call for all required inspections. Complete drawing o everse side. Signed X HenningsBros..__B_y Title: Date: 7-19-90 FOR EPA�A'T USE ONLY 61 Application Accepted by Date r _ Area Pit or Grout Inspection by Date - Final Inspection by y Date r r Additional Comments: d 110� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mentece 823-7104 ❑ Tracy 835-63.85 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - CK d FEE )NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY //DATE PERMIT'NO. ♦.EH 13.241REV.I/Hb) EH t4-28