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! fi APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA� Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Gf 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 Health District. Job Address 12749 W.' SChUite Rd. Trac - City y Lot Size 42.71 Acres pm_ i d Owner's Name Steve ,�� T Address447 MIllon Ct Trac G Phone 8$5-1545 Hennings Bros. l Contractor 9 Address 3525 Pel ands 1 e, Tracy License INo. 290$13 Phone_ 545-11$5 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK pnta 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 Dia. of Well Casing 5 rr (Domestic/Private )QGravel Pack fl Tracy Type of CasingPVC Specifications F1 Public H Other Ll 1�Q1 Delta Depth of Grout Seal Type of Grout Bentonite 1 f Irrigation Alk-Approx. Depth I I Eastern Surface Seal Installed by j [ drl)ler Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') {} t 1r+Depth Filler Materia! (Below 50'I is , i r TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTIONI 1 lNo jSeptic system permitted if public sewer is available within 200 feet.) Installation will serve:.' e'sic!6 ce`�: Commercial Other----------------- Number of living units: Number of bedrooms (( Character of soil to a depih of 3 feet: i t + SIMI Water table depth SEPTIC TANK ❑ Type/Mfg Capacity f No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal Distance 10 nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line S,F. SEEPAGE PITS I ] Depth Size _ Number M' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby rtity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 rules an cJ regulations of the San Joaquin Local Health District. h { Home o ner 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 l employny person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifie 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 lav s of California." The adplicant must call for all required inspections. Complete drawing o re arse si 5igngtl X Ffennil! Br Title: tv Date: 5-2-91 /� FOR DEPART ENT USE ONLY d Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date .� 6 % Additional Comments; S �,�g_J,t'T-./U ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO CARECEIVED ♦ EH 13-24(REV,t/n5l EH 14-26 9400 �