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} APPLICATION FOR PERMIT 1 Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 compliance with San Joaquin CountyOrdinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local HealthDistrict � r -� - � C 4d� 022e—o/ Job Address )e Army Depot — City Lot Size PM r L--335;— Owner's Name Diede Construction Address R.O. BOX 1007,_Woodbridge Phone W_ ` Contractor Hennings-Bros.- Address 3525 Pelandale, Mod.- License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT �A DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 24 pia. of'11Vell Casing 14 ❑ Domestic/Private [A Gravel Pack ❑ Tracy Type.of Casing Steel Specifications 11 104�t 34 conductor X)(Public n Ll Other {_l Delta Depth of Grout Seal Type of Grout Ce .. Tt I I Irrigation —,-Approx. Depth I I Eastern Surface Seal Installed by driller _ Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material Itop 501 S� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION LI DESTRUCTION i I.(No septic system permitted if public sewer is available within 200 feet.1 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 Capacity-- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 ' SEEPAGE PITS l I Depth Size _ Number SUMPS ❑ 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 Diltrict. 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 er ide. 0 ; Signed Hpnninne Rrnao r_ Title: ).... Date: 10-17-F3�3 FOR DEPARTMENT USE ONLY Applicati n(Accepte by ( Date 7 v Area I it o GrOuf`Ihspection0?� Dat r� / Final Inspection by Date Additional Comments: '� �� — 9� a. �P -"S�CX1"•1J� ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-71a Lb Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 [fi/1'�'1�J11.r.'1�., fo � �FrK!,�t�•Lsr` ; FEE AMOUNTDUE AMOUNT REMITTED RECEIVED BY DATA: PERMIT'NO.- *M INFO CASH r.EH 13-241REV .!/N51 EH 1428 - EE