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APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT r ;J 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 - PERMIT EXPIRES TYEAR FROM DATE ISSUED I'I (Complete in Triplicate) Application is hereby made to the San Joaquinf Local Health District for a permit to construct and/or install the work herein described. This application is made in conapllancetwrth San'Joaqurn County Ordinance4No 549•for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health`Drstrrct-741 a a "' x^wt < (N Job Address City Lot Size PM N � Inn Owner's NameBanta .I n–DaVp. Rnriand AddressS 7th I PhonealV'-s I Contractor Henn i ngs Bros 'Address 352.5 License No.�$ Phoned – TYPE OF WELL/PUMP: NEW:WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATIION ❑ SYSTEM REPAIR [I OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE-OF WELL PROBLEM AREA �YCONSTRUCTION SPECIFICAT10N:S— v°"I" ❑ Industrial ❑ Open Bottom iI ❑ Manteca Dia. of Well Excavation a Dia. of Well Casing t' ' ❑ Domestic/Private EX Gravel Pack ❑ Tracy Type of Casing i S ifications f" Public n Other El Delta Depth of Grout Seal t e fi Grout ��o I i Irrigation ---Approx. DepthI"I Eastern Surface Seal Installed by dr-i.1e1^ Repair Work Done Ll Type of Pump f H.P. State Work Done � i Well Destruction ❑ Well Diameter i Sealing Material (top 50') Depth p Filler Material /Below 50') E �` TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system er r e r pu r ewer is available within 200 198V,feet.I Installation will serve: Residence Commercial_ Otherf �.+ '- Number of living units: Number of bedrooms ) Character of soil to a depth of 3 feet:I i Waterf PKG. TREATMENT PLT. " SEPTIC TANK LJType/Mfg IM Capacity No. Compat "-i- 171II Method of Disposal Distance to nearest: Well Foundation props'–h Th T LEACHING LINEC No. & Length of limes Total length/8l% _ 6 y FILTER BED ❑ Distance to nearest: Wellf property Linlie pzj, –, W` f r-11 !� d38 SEEPAGE PITS l I Depth I k Size Number SUMPS Ll to nearest: Well Foundation pro °tir I 'I A--�iLTH I DISPOSAL PONDS EJpe tY �i't I CEs hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanlaws, ander rules and regulations of the San Joaquin1ocal Health Dices, state strict. t 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 j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature j 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." P The applicant must tali for all required inspections. mp to dr wing on reverse side. r j 6 Signed X Hellfll 1 Bros B { Z./2«� Date: 4-26-8$ FOR ARTM USE ONLY Application Accepted by /jamDate Area Pit or Grout Inspection by // Date . ;Z Final Inspection by Date .I� Additional Comments: _r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE AMOUNT DUE ' AMOUNT REMITTED INFO DATE PERMIT NO. EH.'I 3-24 51 1REV.t �J} �� 7 K/ RECEIVED BY ♦.EHI 1�26inT