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APPLICATION FOR PERMIT Ma �? I SAN JOAQUIN LOCAL HEALTH DISTRICT f �! 1601 E. HAZELION AVE., STOCKTON, Cf, Telephone (209)A66-6781 N1AR 2 € PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in'Triplicate) ENVIROMENITAL HEALTH FERMIT/SERVICES Application is heteby 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 Health District. Job Address River Rd.- 5,904'. south o� River .Rd. , here CArroltono!W1., dead ends- ista River Rd. ze •Lt/o~Robert Winters _ Owner's Name -Wi nden—Fop` S - =T_�x Address 1$499 Jacictone,Mantzca Phone L Contractor Hennlncjs OS._ ' Address_35 _P_eIandale_ _-Mod_ License No.74(181'1 Phone _TYPE OF WELL/PUMP:. 4 NEW WELL-AX —WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ ,. OTHER _❑ DISTANCE TO NEAREST: SEPTIC TANK ROn� SEWER LINES _ DISPOSAL LFFLD.� - PROP LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation 2fi a Dia. of Well Casing 11 e ❑ Domestic/Private UGravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 171 Other ❑ Delta Depth of Grout Seal a19? Type of Grout Mrrigation _.-Approxi 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 hop 50') Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 lNo 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 z t SEPTIC TANK ❑ Type/Mfg "Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size �•.i FILTER BED ❑ Distance to nearest: Well Foundation Property Line Tj = SEEPAGE-PITS .,,_ I l ..Dapth Size SUMPS ❑ Distance to nearest: Wel! 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." 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• i } tion laws of California." The.applicant must call for all required inspections. Complete drawing on revers side- Signed X__ Henn l ng S Bros. 8y Title 4 Date: -1-$8 ' FOR DE PA MkNNT USE ONL i Application Accepted by Date -3—Ze_—Ir�, Area Q ti Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: j ❑ 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., P.O. Box 2009, Stk., CA 95201 9 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 6 RECEIVED BY DATE PERMIT'NO. i + EH 14-26(RpV.I/K5) �.